Frailty Practitioner (18 hours per week)
| Dyddiad hysbysebu: | 11 Chwefror 2026 |
|---|---|
| Cyflog: | Heb ei nodi |
| Gwybodaeth ychwanegol am y cyflog: | Negotiable |
| Oriau: | Llawn Amser |
| Dyddiad cau: | 08 Mawrth 2026 |
| Lleoliad: | Gloucester, GL4 4BL |
| Cwmni: | NHS Jobs |
| Math o swydd: | Parhaol |
| Cyfeirnod swydd: | A1897-26-0000 |
Crynodeb
Please see the attached document for more details. Key Responsibilities Moderate and Severe Frailty Case Identification: Use Personal Proactive Whiteboard to identify list of potential patients living with moderate or severe frailty, supported by sub-cohort analysis, with the aim of identifying the highest risk patients Holistic Assessment: - Provide support to the Care Coordinator to ensure the self-assessment questionnaire process is carried out effectively and to a high-quality standard - Triage potential patients to determine which will receive a comprehensive geriatric assessment (CGA) - Determine what action to take with those patients who do not receive a CGA and ensure those actions are undertaken - Undertake CGAs as determined for relevant patients, inputting information into the digital template and ensuring they are given a Rockwood Score. Draw in clinical support as required from the PCN Frailty Teams GP with an interest in Frailty for those patients with a higher acuity of need Personalised Care and Support Planning: - Ensure a Personalised Care and Support Plan (PCSP) is produced and agreed with the relevant patient and any carer/family, along with a ReSPECT plan Coordinated and Multi Professional Working: - Ensure close multi-professional and multi-agency working, especially with other members of the local Integrated Neighbourhood Team(s), to facilitate the delivery of each patients PCSP Continuity of Care including reviews - Support the Care Coordinator to ensure regular review of patients take place as planned and agreed according to the individual needs of the person and /or following trigger events such as hospital admission Dementia Co-diagnosis - Determine the frequency of MDT meetings, depending on demand; keep under regular review - Support the Frailty Team Administrator to ensure all post MDT meetings are carried out in a timely and effective manner General Leadership: - Provide leadership and support to the Health and Wellbeing Coach and Care Coordinator(s) - Clinical Leadership: Provide clinical assessment, diagnosis, and case management of people living with frailty in the community using agreed standardised tools and templates. Responsible for frailty team care coordinators, frailty team administrators, managing caseloads and ensuring the appropriate allocation of personnel and tasks to team members Partnership Working: Build and maintain effective working relationships with GPs, acute and community hospitals, Adult Social Care, voluntary sector organisations, and other community services to deliver integrated care Care Coordination: Ensure seamless transitions of care and continuity through proactive case management and liaison with all relevant stakeholders MDT Coordination: Lead and participate in MDT meetings, ensuring collaborative care planning and shared decision-making across system partners Education and Training: Support the development of frailty awareness and skills for other practitioners, carers, and patients Service Development: Contribute to the design, implementation, and evaluation of frailty pathways and services Risk Management: Identify and manage clinical risks, including falls, polypharmacy, and cognitive decline Patient Advocacy: Promote shared decision-making and ensure care aligns with patients values, goals and what matters to them Data and Audit: Collect and analyse data to: - support risk stratification and segmentation of the patient cohort, - enable use of the Personalised Proactive Whiteboard for care coordination, - monitor outcomes and measure impact, - support quality improvement and inform commissioning conversations. Knowledge, Skills and Experience - Advanced clinical assessment and diagnostic skills, particularly in geriatric and frailty syndromes. - Expertise in frailty identification and screening tools (e.g. Clinical Frailty Scale, eFI). - Sound understanding of long-term condition management, rehabilitation and end-of-life care. - Proven ability to work effectively within MDTs and across organisational boundaries. - Understanding of personalised care, wider determinants of health and equality, diversity and inclusion Excellent communication and interpersonal skills to: - engage with and enable people, families and carers using health coaching approaches - enable efficient multi-agency working with practitioners across the system adopting a team of teams approach, especially with the local Integrated Neighbourhood Team Competence in using digital health records and remote monitoring tools.