Ageing Well Practitioner

The Calderdale Collaborative Community Programme Board have identified the opportunity to improve outcomes for individuals and provide care closer to home through identifying people at rising risk of frailty. This scheme seeks to identify people in the mild to moderate and severely frail category, identifying the needs and strengths of individuals and matching interventions delivered by the appropriate member of the healthcare team.

This is an opportunity for a registered nurse, physiotherapist or occupational therapist with a background in frailty/elderly care with acute and community experience to take on a 12-month fixed term contract / secondment within the Calderdale Community Teams.

If you wish to discuss further, please Liz Morley Associate Director for Nursing, Community Division

(07747 630989
) or Jennifer Clark, Associate Director of Therapies (07500 312136).

You will be allocated to a geographical base, but this may change dependent on service need. You may be expected to work across the five PCNs or CHFT hospital sites as required.

The majority of clinical work takes place within patient’s homes (including care homes). However, we also see patients in clinics or groups when it is more appropriate to do so. At times, the team visits patients in hospital to participate in meetings, or to assist complex discharge planning. You will therefore be required to use a car with appropriate business insurance.

The service has close links with the Frailty and Community Rehabilitation Teams, Urgent Community Response, GP practices, Intermediate Care Beds, Stroke Early Supported Discharge pathway, Community Matron and District nursing teams. This allows for seamless transfers of care between community services.

We are committed to recruiting to our values. Leading One culture of care underpins our Four Pillars by creating an environment, tone and behaviours across all parts of the Trust that are fundamentally rooted in compassionate care.

We are open to considering a wide range of flexible working arrangements. There are opportunities to flex the days of the week, hours and times of work and place of work including: part-time, job-share, flexible working hours and the possibility to work from home when appropriate. Please talk to us during the interview process to discuss any flexibility that you may require.
- Work with GPs, other clinicians and managerial colleagues to identify patients within the PCN who present as a rising risk of those who are mild to moderately frail.
- Consult with the patients and carers of patients who are identified as frail, to assess their needs and provide examination where necessary.
- Recognise and adapt communication to suit the needs of the individual.
- Make decisions about the treatment, referral(s) and care planning, both autonomously and in collaboration with GPs and other clinical colleagues.
- Interpret the results of diagnostic tests, such as ECGs, X-rays and pathology screens.
- Undertake or work towards an independent prescribing module. Therapists to work within patient group directive plan.
- Ensure clinical practice remains safe and effective and within the boundaries of competence with acknowledgement of personal and professional limitations.
- Provide counselling, health promotion and health education to patients and their carers.
- Identify disease factors and early signs of illness
- Ensure the clinical computer system(s) are maintained with accurate details documented and amended as contemporaneously as possible.
- Develop, with community and PCN colleagues, ongoing care plans for patients.
- Hold a locus of expertise in frailty management and be able to assess and deliver treatment at a highly specialist level in the areas listed but not limited to:

- Triage and prioritisation of referrals
- Physical rehabilitation
- Supporting patients and carers in coming to terms with their condition.
- Supported self-management to promote independence and quality of life, training carers as required.
- Assessment of the patient’s environment including home, work or leisure.
- Assessment for assistive and adaptive equipment, including telecare.
- Complex psychosocial assessment of patients and carers, including understanding the impact of any mental health disorders including dementia and depression.
- Assessing and treating cognitive dysfunction.
- Using a variety of outcome measures appropriate to the approach being delivered.
- Transfer of care and planning exit strategies from the service.
- To work in an interdisciplinary manner, being able to debate skill sharing, and through training become competent to take on aspects of blurred boundary working.
- To participate in the supervision of Nursing and Occupational Therapy students (in the role of Clinical Educator) and other health and social care students, helping them meet their development needs.
- To ensure a high standard of care is provided, including developing, implementation and review of clinical