Advanced Nurse Practitioner - Frailty

Clinical responsibilities • To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team. • Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes. • Completing and sharing advanced care plans • Partnership working with other providers to deliver seamless joined up care. • Reviewing and making clinical decisions, including prioritisation of need. • Provide highly specialist advice to others regarding the management and care of patients/service users. • To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures. • Plan, implement and review health improvement programmes in a range of settings. • Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met. • To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation. • To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour. • To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints. • Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state. • Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home. • Referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources. Responsibility for Information / Data • To maintain and ensure the highest quality of recording of patient data into the relevant record system in line with professional guidance. • To maintain confidentiality and comply with required Data Protection and other IG requirements and best practice. Professional Responsibilities • Ensure that personal performance meets job requirements, Professional Codes and standard • Ensure the required level of IT competence required for the role to process, record, evaluate, analyse and report data. • Demonstrate commitment to the role and to service improvement through developing relationships with key partners, innovative thinking and small scale project management. • Provide a positive, compassionate role model to junior staff and colleagues to ensure the delivery of people centred care and the key components of compassionate care • Create effective team work across professional boundaries using team building skills, creating common goals, and through engagement. • Respect and apply the requirements of equality and diversity, promoting and role modelling these across the multi-disciplinary team. Other Responsibilities • To provide holistic assessment of older adults living with frailty • To participate in the delivery of education and training to staff within the PCN as appropriate. • To undertake urgent visits to patients in their own homes. • To be able to recognise deteriorating patients and to respond appropriately. • To work as part of the frailty team to provide pro-active and enhanced clinical management for patients within their own homes to reduce admissions to hospital and urgent referrals to primary care. To work flexibly to meet the demands of the service and adapt to changing priorities within the working day/week Job description Job responsibilities Clinical responsibilities • To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team. • Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes. • Completing and sharing advanced care plans • Partnership working with other providers to deliver seamless joined up care. • Reviewing and making clinical decisions, including prioritisation of need. • Provide highly specialist advice to others regarding the management and care of patients/service users. • To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures. • Plan, implement and review health improvement programmes in a range of settings. • Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met. • To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation. • To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour. • To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints. • Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state. • Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home. • Referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources. Responsibility for Information / Data • To maintain and ensure the highest quality of recording of patient data into the relevant record system in line with professional guidance. • To maintain confidentiality and comply with required Data Protection and other IG requirements and best practice. Professional Responsibilities • Ensure that personal performance meets job requirements, Professional Codes and standard • Ensure the required level of IT competence required for the role to process, record, evaluate, analyse and report data. • Demonstrate commitment to the role and to service improvement through developing relationships with key partners, innovative thinking and small scale project management. • Provide a positive, compassionate role model to junior staff and colleagues to ensure the delivery of people centred care and the key components of compassionate care • Create effective team work across professional boundaries using team building skills, creating common goals, and through engagement. • Respect and apply the requirements of equality and diversity, promoting and role modelling these across the multi-disciplinary team. Other Responsibilities • To provide holistic assessment of older adults living with frailty • To participate in the delivery of education and training to staff within the PCN as appropriate. • To undertake urgent visits to patients in their own homes. • To be able to recognise deteriorating patients and to respond appropriately. • To work as part of the frailty team to provide pro-active and enhanced clinical management for patients within their own homes to reduce admissions to hospital and urgent referrals to primary care. To work flexibly to meet the demands of the service and adapt to changing priorities within the working day/week