Frailty Lead (Community Matron / ACP / ANP / Advanced Paramedic)NHS

Job summary

This role will support all our PCN practices to complete home visits and on-going care to those who need it need it most, or those who have recently been discharged from hospital.

As the team grows, we would expect this Frailty Lead to provide mentorship and clinical support to staff in the team, including Nursing Associate and HCA roles.

This is a growing and evolving role, and so flexibility to engage with future ICB and neighbourhood Frailty initiatives would be required.

Ideally a prescribing Advanced Nurse Practitioner or Advanced Care Practitioner will be best suited to this role. You will work with a high degree of autonomy in the community.

(Note advert is for x2 roles)

Main duties of the job

Primary Responsibilities

There may be, on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:

• To work with older people in surgery and out in the community including care homes.
• To manage their own caseload.
• Engage individuals as active partners in their treatment and support.
• To support onward referral to secondary and specialist services where indicated.
• To develop and maintain close relationships with the surgery teams.
• Maintain patient records.

Secondary responsibilities

• To assertively engage with service users, striving at all times to develop good relationships, becoming a trusted person.
• To develop professional networks, have an understanding of local resources in order to ensure that the service user is able to navigate the full health and social care system.
• To promote awareness of the professional role across the PCN.
• To demonstrate effective communication skills with people in an age-appropriate way and those whose understanding may be impaired
• To act within the appropriate professional code of conduct at all times
• To ensure that up to date written and electronic records and activity data are maintained in accordance with Professional standards and to provide specialist reports relevant to practice setting.
• To keep accurate and timely written and electronic record of each contact, using SystmOne and EMIS.
• To promote and safeguard the welfare of vulnerable adults.

Job description

Meridian is recruiting to a Community Frailty team, caring for our most frail, vulnerable and complex patients in the community. This role will focus on the assessment, triage and multi-disciplinary referral of multi-morbid and frail patients, including those that are housebound, living in care homes or recently discharged from hospital. This role will include semi-urgent and routine care, including visiting those living in the community with frailty and multiple long-term conditions. You will be working within the practices and with colleagues in CPFT and secondary care.

This role will support all our PCN practices to complete home visits and on-going care to those who need it need it most, or those who have recently been discharged from hospital.

As the team grows, we would expect this Frailty Lead to provide mentorship and clinical support to staff in the team, including Nursing Associate and HCA roles.

This is a growing and evolving role, and so flexibility to engage with future ICB and neighbourhood Frailty initiatives would be required.

About us

Primary Care Networks and Integrated Neighbourhood Teams are a new way of working that enables health and other services to work together to provide better access for patients.

PCNs build on existing primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care for people close to home.

We are hoping successful applicants will help us create new ways of working with partner organisations we need someone highly motivated, keen to help shape how communication can be improved between partner organisations to improve patient care.

Our PCN

The Meridian PCN is a collaboration of six GP surgeries across Cambridgeshire and North Hertfordshire; supporting a patient population of +48,000.

• Bourn Surgery
• Comberton & Eversden Surgery
• Harston Surgery
• Orchard Surgery - Melbourn
• Roysia Surgery - Royston
• Monkfield Medical Practice - Cambourne

Our Aims

• Support the local interpretation and implementation of NHS transformation plans
• Design and deliver primary care services at scale.
• Provide the operational people and infrastructure to allow practices to collaborate
• Be a voice for Primary Care, one that enables what we all want; sustainable and clinically excellent general practice