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Oldham North Primary Care Network Clinical Frailty Practitioner
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Job Overview The Population Health Management PHM Clinical Frailty Practitioner will work across the PCN to support the delivery of the Oldham North Population Health Management Programme. This programme is focussed on providing more proactive support and case management to people over 65 with mild/moderate frailty, to keep them healthier for longer in their own homes. This is an exciting time to join Oldham North PCN and this is a pivotal role in delivering a pioneering health improvement programme. The role will involve leading the assessment of patients over 65 with mild to moderate frailty who are suitable for the programme, developing care plans for these patients and managing ongoing monitoring and review of their care.
The post holder will also be responsible for supporting leadership of the PHM Programme to identify and engage people to intervene early to maintain good health, prevent deterioration and ensure they are able to access services which meet their range of needs. The postholder will provide leadership to the PHM Frailty Care Co-ordinator and will work closely with the PCN Frailty Lead. He/she will work with the wider PCN team and across an integrated neighbourhood team of different health and care professionals involved in the care of this group of patients. This role involves patient facing care, and the post holder will be responsible for providing support directly to patients and their carers.
Main Duties and Responsibilities Provide clinical leadership and supervision to the PHM Care Co-ordinator and other staff involved in the delivery of the Oldham North frailty model, particularly for the management of care pathways of patients with complex cases. Conduct comprehensive geriatric assessments to holistically assess the different needs of patients with mild or moderate frailty and identify those with complex needs and produce accurate and complete records of the patient consultation, consistent with legislation, policies and procedures. Refer patients to health, care and other wider community-based services as needed for continuation of care where appropriate. Conduct assessment of patient activation in their own health to support referrals to health coaching where relevant Develop and implement person-centred shared care plans for patients, in collaboration with patients and through shared care planning with different healthcare professionals including those across primary care, community health services, secondary care, mental health services, social prescribing and social care.
Support continual process improvement for the programme and make iterations in partnership with the Integrated Neighbourhood Team and PCN team as appropriate, including a. identifying where there may be health inequalities and providing feedback on where engagement could be enhanced; b. overseeing the quality and effectiveness of the PHM programme and working with the PCN team to use data and feedback to improve processes; c. exploring the mechanisms to develop new ways of working.
Monitor and evaluate the quality and effectiveness of the PHM programme, using data and feedback to identify areas for improvement and innovation. Provide education to staff, patients and carers on topics related to frailty, ageing and chronic conditions, as well as proactive management pathways. Follow up with patients who do not wish to engage to ensure that they are given an opportunity to enrol if they change their minds. With the Care Co-ordinator, help maintain a log recording the journey of each patient on the PHM programme, including the services they are referred to.
Provide expert advice to patients and their carers using expert knowledge and clinical skills to deliver holistic care. Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating. Evaluate patients response to health care provision and effectiveness of care. Use technology and appropriate software e.g., EMIS and Graphnet as an aid to management in planning, implementation and monitoring of care, presenting and communicating information.
RESPONSIBILITIES TO PCN TEAMS Actively develop effective working relationships and lines of communication with the Frailty Lead, within the individual practices, with the PCN, and with wider multi-professional teams across North Integrated Neighbourhood team e.g. District Nursing, Occupational Therapists, Mental Health and Adult Social Care Services, as well as Social Prescribers and Pharmacists. Demonstrate the ability to work effectively as a member of a team with the practices and PCN Care Coordinator as a key person within the PHM model. Recognise personal limitations and refer to more appropriate colleagues when necessary.
Follow through with service users and others involved to ensure all services and care arrangements are in place. Develop an in-depth knowledge of lo
