Intermediate Care and Frailty Practitioner

Job summary

The post holder will be an integral member ofthe multi-disciplinary Halton Intermediate care and frailty team (UCR) andVirtual Frailty ward Halton.

The primaryfunction of the role is to maximise the patients health, clinically assess andtreat patients in a defined group and reduce risks that contribute to illhealth, thereby reducing unnecessary admissions to acute services, reducingdemand on GP time and facilitating the delivery of efficient, effective,co-ordinated and timely high quality care to frailty patients and patients inthe community.

Please contactLydia Vallance-Prentice for anyinformation regarding this post.

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Main duties of the job

Pleasesee the full job description and person specification attached as a separatedocument for the full list of roles and requirements

About us

Flexible working will be considered for all roles.

Unfortunately, we do not hold a sponsor licence for working Visas.

At Bridgewater, our PEOPLE values shape how we deliver ourNHS services in your local community.

They help us deliver our mission to improve local health andpromote wellbeing in the communities we serve.

After all, values are about people and they werecreated in partnership with our staff to reflect what they felt was importantto them

Here at Bridgewater our shared values flow through the organisation.

P - Person-centred-We are passionate about individual needs andpromote independence in the healthcare we provide..

E - Empowered- We empower our people and encourage new ideas to deliver and create improvements in community care.

O - Open and Honest -We behave in a way that develops relationshipsbased on trust, openness, honesty and respect.

P - Professional-We support our people, so everyone has the rightskills and training to deliver outstanding patient care.

L - Locally Lead -We are always learning about our communities andshow great pride in being a local provider of health and care.

E - Efficient -We use our resources wisely to providesustainable and value for money healthcare for our patients.

Job description

Job responsibilities

The post holder will

Undertake clinical assessment and provide treatment for patients within the defined group. Link with existing services to facilitate early discharge from hospital and prevent re-admission. Develop Partnerships and joint working within the wider local health and social care economies. Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of health

Clinical Requirements:

The post holder will

Conduct a comprehensive healthcare assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include: Review of health assessment including medical history Physical examination Assessment and review of medication Making referrals for diagnostic tests Functional /cognitive assessment Refer to Social Care partners for assessment. Maintain contemporaneous and accurate clinical records, recording all patient related activity on the clinical systems / databases in accordance with NMC, national legislation and local and national standards Develop, monitor and manage the plan of care in collaboration with the primary health and social care team and others.

Application of clinical knowledge about long term conditions

Analysis of symptoms and data

Identification of risk factors associated with exacerbation of patients condition

Recognition of early signs and symptoms of acute illness.

Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected.

Documentation of progress and continuous reassessment

Referral and investigation

Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs. Co-ordinate care and treatment to avoid fragmentation, duplication and delay, in the least intensive setting appropriate to the patients needs by:

Prioritisation and co-ordination of multiple health needs.

Referrals to specialist services.

Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments.

Integration across health and social care (inc. voluntary sector and housing).

Identifying deficiencies in service provision and address these as appropriate

Be aware of and adhere to, the Professional bodies (NMC) Standards and NMC Code of Conduct. (AHPF). (HCPC).

Leadership Requirements

The post holder will

Lead the process of identifying their caseload through interpretation of the information available on EMIS (clinical IT system) and contribute to the collection of data to monitor outcomes measures Participate in the development of case management across Frailty Services. Provide clinical leadership and mentoring Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of patients, thus promoting continuity of high quality patient centred health and social care. Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviours. Act as a role model so that patients receive the most effective care possible through:

Encouraging optimum management of long term conditions to ensure that the patient is functioning at the most independent level possible

Acting in patients interests at all times

Contributing to the development of policy and services to reflect the needs of the patient caseload.

MANAGERIAL RESPONSIBILITIES

The post holder will

Manage the complex clinical interventions of individuals within an identified patient group on an ongoing basis. Undertake risk assessment in relation to individuals within the client group Monitor and respond to the development of changing clinical and social situations with the identified patient group without recourse to others where possible. Ensure the safe management of care and service delivery Performing appraisal, personal development reviews and the application of staff management procedures.

Service Development Requirements

The post holder will

Encourage patient participation in case management

The provision of information about disease prevention, progression and outcomes.

Ensure that services are accessible to increase patient confidence

Empowering the patient to self manage whenever possible.

Contribute to the development of role and service redesign in frailty management.

Analytical and Information Requirements

The postholder will utilise data and data tools (including databases) to produce appropriate monitoring reports on both patient care and service outcomes and produce appropriate communication for patients.

Clinical Governance Requirements

The post holder will

Participate in individual and group clinical supervision and to take responsibility for developing own learning. Participate in research and audit relating to Frailty management Ensure systems are in place for ongoing review and assessment of care provision and delivery. Improve quality via Clinical Governance, Essence of Care and Clinical Supervision, by working closely with colleagues to address competency levels within the service. Report any incidents through application of trust policies. Participate in patient satisfaction reporting to improve patient care.

Education and Training Requirements

The post holder will

Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and provide mentorship and teaching to others developing a frailty service Participate in the induction of new staff. Provide education, advice and support to health and social care staff, people with long term conditions and their carers in both community and acute settings. Maintain up to date knowledge and competence in line with professional and service requirements and demonstrate critical thinking, decision making and reflective skills to ensure own professional development.

Communication/Relationship Requirements

The post holder will

35. Liaise with patients, community and specialist nursing and other health professionals, GPs, acute colleagues, social care colleagues and the voluntary/charitable and non-NHS sector.

Work with patients to:

Ensure that their values, beliefs and views are reflected in the case management plan

Encourage active participation in case management

Ensure that health advice is provided in a professional, accessible and supportive way.

Work with other professional and statutory groups involved in case management to:

Ensure that there is consistent and high quality implementation of care

Avoid duplication, delay or distress to patient

Ensure that record keeping is consistent with Trust and Professional standards.

Communicate at all levels of the organisation to a variety of health and social care professionals to provide best outcomes for patients.

Level of Independence/Freedom to Act

The post holder is required to execute the duties of this role without reference to others. This includes undertaking an advanced level of clinical assessment, the application of critical thinking, high level decision making and the delivery of specialist care and treatment. The post holder is expected to abide by their professional code of conduct when exercising autonomy and to safeguard the interests of patients.

Health and Safety

41. In accordance with the Health and Safety at Work Act 1974 and other supplementary legislation, you are required to take reasonable care to avoid injury during the course of work and co-operate with Trust and others in meeting statutory regulation. You are also required to attend statutory training as required to fulfil your duties.

42. To comply with safety instructions and Trust Polices and Procedures.

43. To use in a proper and safe manner, the equipment and facilities provided.

44. To refrain from wilful misuse of, or interface with, anything provided in the interest of health and safety and any action, which might endanger yourself and others.

45. To report as soon as practical, any hazards and defects to your senior manager.

46. To report as soon as practical, accidents and untoward incidents and to ensure accident forms are completed.

This list of duties is not intended to be exhaustive, but indicates the main areas of work and may be subject to change after consultation with the post-holder to meet the changing needs of the organisation

Person Specification

Experience

Essential

Experience of working with patients with long term conditions Experience of successful multi agency working including an understanding and experience of working in a social care environment Evidence of influencing, motivating and negotiating with others to achieve change in relation to care.

Desirable

Specialist practitioner Evidence of post registration or qualification study on management of COPD, Diabetes or Coronary Heart Disease

Sponsorship

Essential

Do you have the right to stay and work in the UK without sponsorship (share-codes will be checked if applicable), please state this on your application form

Other

Essential

Clinical Assessment skills Moving and handling skills (including ability to assess need) Clinical decision making Venepuncture Supplementary prescriber* Palliative/end of life care skills

Qualifications

Essential

Relevant Clinical Professional Qualification Evidence of continued Professional Development Extensive post registration experience. Management/Clinical Leadership experience Clinical diagnostics Msc level and or Clinical Examination Msc level Working towards V3oo independent prescribing or willing to undertake this.

Skills & Attributes

Essential

Understanding of the principles of case management Awareness of long term condition management agenda Awareness of current national and local agenda in health and social care for frailty Evidence of being able to communicate complex information and advice on healthcare to patients/carers and colleagues Ability to work under pressure and manage a diverse work load Excellent interpersonal skills; including negotiation, influencing and presentation Risk Assessment skills Ability to understand and analyse complex data Self-management and motivation skills Confidence to challenge traditional practice and persistence to address difficult issues Networking knowledge and understanding of local services

Desirable

Independent prescriber V300 Awareness of factors which contribute to good health and the importance of promoting these in line with organisational public health policy

Relations

Essential

If you are related to a director or have a relationship with a director or employee of an appointing organisation, please state the relationship in your application form.

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