Enhanced Frailty Health and Social Care CoordinatorNHS

Job summary

The Enhanced Frailty Team, in conjunction with the wider multi-disciplinary team, comprises of a Consultant Geriatrician, Chief Medical Officer, Enhanced Frailty GPs, Enhanced Frailty Nurse Practitioners, and Frailty Care Coordinator / Prescribers.

The purpose of the Frailty Team is:

• To provide integrated, pro-active care for people in Harrow aged 65 years of age or over, or identified as frail, with multiple complex long-term conditions, who require more intensive support and care in the community
• To reduce avoidable hospital admissions / re-admissions or A&E attendances
• To support Harrow GPs with intensive case management of these more complex, vulnerable patients to improve the health and wellbeing of patients by providing proactive, responsive and intensive case management

Main duties of the job

The Post Holder will be a highly competent individual, who will play a key role in co-ordinating the Frailty Team activities and act as a Social Prescriber for patients and their families / carers as needed. They will work with members of the team and other health and care providers to share information to jointly plan care and provide a streamlined service.

The post holder will be performance managed with clear objectives designed to evidence your success in delivering excellent patient satisfaction and health outcomes, supporting the Frailty Team patient caseload, developing colleagues skills, and lastly supporting patients to avoid unnecessary hospital admissions.

Job description

Main Responsibilities

• Work with GP Surgeries to identify potential referrals to the Tier 2 Frailty Service
• Working with Frailty Team colleagues, use risk stratification tools to identify patients at risk and ensure they receive assessment and care in a timely fashion
• Support the Frailty Team in the delivery of Complex Care, coordinating care delivery between service providers as needed
• Make Social Prescribing referrals, as appropriate
• Contribute to planned team huddles and multi-disciplinary team meetings
• Hold regular welfare calls with the patient / carer
• Maintain excellent working relationships with all those involved in the provision and development of services for those with long-term conditions, sharing regular updates of planned care and any changes when they occur
• Work closely with the Frailty Team and others involved in care delivery to ensure patients have relevant referrals and access in place; attend and liaise with the Frailty Team MDT groups, regularly attending case conferences and providing relevant updates

Communication Skills

The post-holder will recognize the importance of effective communication within the team and will strive to:

• Communicate with patients in a welcoming way, which is non-judgmental and respects patients feelings, circumstances, and rights
• Utilise and demonstrate sensitive communication styles to ensure patients are fully informed of reasons for contact when contacting them for example, on welfare calls
• Communicate highly sensitive patient information and progress effectively with other team members and outside relevant health and social care providers, as appropriate
• Ensure all documented notes are contemporaneous

Supporting Responsibilities

Quality

• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance
• Participate in the management, review, and identification of learning from patient complaints and significant events
• Deliver evidence-based care according to the National Institute for Clinical Excellence (NICE) and Care Quality Commission (CQC) guidelines

Information Technology

• Possess basic computing and keyboard skills
• Have a good working knowledge of relevant areas of clinical systems and other programmes as appropriate to the role
• Demonstrate a good working knowledge of the policy on information and clinical governance

Research and Audit

• Contribute to the collection of data for research/audit purposes
• Identify audit topics relevant to the Frailty Team

Professional and Educational Responsibilities

• Ensure all Statutory and Mandatory training is complete
• Avail of all opportunities to develop both clinical knowledge and practical skills

About us

Harrow Health CIC

Harrow Health CIC began in 2007 by a group of Harrow GPs, whose sole aim was to ensure patients receive a high quality clinical care service within the community. Over the years, Harrow Health has expanded. We now provide many clinical services, which include Mental Health Services, Elective Services, and our Whole Systems Integrated Care Services.

Our Vision:

To provide high quality patient care, enhancing patient experience by providing excellent clinical effectiveness in a safe environment; working in partnership to provide gold standard services and develop a sustainable future for the local health community.