South Kerrier INT Frailty Lead

Core Responsibilities Provide strategic direction and monitor progress to achieve South Kerrier Neighbourhood objectives. Where appropriate advocate for change across South Kerrier to bring together community and practice teams. Develop, implement and evaluate a seamless Proactive/Frailty support service across South Kerrier, working with community and secondary care where appropriate, and aimed at continuously improving standards of patient care and wider multi-disciplinary team working. Where appropriate, support the development of discharge and contingency plans with relevant professionals to arrange on-going care in residential, care home, hospital, community settings and at home; Assist patients to adapt to and manage their physical and mental health long-term conditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatment plans, with an aim to increase patients productivity and self-care; Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve South Kerrier local population objectives. Advise practices of workflow and develop SOPs for teams and practices to follow and implement, particularly Personalised Care Planning, utilising best practice. Service Leadership • Provide professional leadership for the proactive care frailty service, offering guidance and support to the Proactive Nursing Team and neighbourhood clinical staff. • Maintain clinical oversight of complex frailty patients, including providing direct clinical review where appropriate, to ensure safe and coordinated care across the neighbourhood team. • Lead workforce planning, allocation of resources, and performance monitoring in collaboration with operational managers. Ensure robust clinical governance structures are maintained, including incident review and risk management. MDT Ensure MDTs adhere to the Gold Standard Framework and lead MDT development and best practice across South Kerrier. Ensure the right people are involved in MDTs from the South Kerrier Neighbourhood teams. Participate in GP huddles and any other Partnership MDT and promote effective ways of working; Exercise a critical understanding of personal scope of practice and to identify when a patient requires escalation or referring on to other services. Develop effective working relationships with the Palliative Care Team and embed new processes and ways of working if required, to avoid duplication and to enhance the patient and family experience Complex Case Management Hold a case load of patients across South Kerrier. Prescribe within your individual scope of practice and ensure that prescribing is undertaken in a safe, cost-effective manner. Job description Job responsibilities Core Responsibilities Provide strategic direction and monitor progress to achieve South Kerrier Neighbourhood objectives. Where appropriate advocate for change across South Kerrier to bring together community and practice teams. Develop, implement and evaluate a seamless Proactive/Frailty support service across South Kerrier, working with community and secondary care where appropriate, and aimed at continuously improving standards of patient care and wider multi-disciplinary team working. Where appropriate, support the development of discharge and contingency plans with relevant professionals to arrange on-going care in residential, care home, hospital, community settings and at home; Assist patients to adapt to and manage their physical and mental health long-term conditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatment plans, with an aim to increase patients productivity and self-care; Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve South Kerrier local population objectives. Advise practices of workflow and develop SOPs for teams and practices to follow and implement, particularly Personalised Care Planning, utilising best practice. Service Leadership • Provide professional leadership for the proactive care frailty service, offering guidance and support to the Proactive Nursing Team and neighbourhood clinical staff. • Maintain clinical oversight of complex frailty patients, including providing direct clinical review where appropriate, to ensure safe and coordinated care across the neighbourhood team. • Lead workforce planning, allocation of resources, and performance monitoring in collaboration with operational managers. Ensure robust clinical governance structures are maintained, including incident review and risk management. MDT Ensure MDTs adhere to the Gold Standard Framework and lead MDT development and best practice across South Kerrier. Ensure the right people are involved in MDTs from the South Kerrier Neighbourhood teams. Participate in GP huddles and any other Partnership MDT and promote effective ways of working; Exercise a critical understanding of personal scope of practice and to identify when a patient requires escalation or referring on to other services. Develop effective working relationships with the Palliative Care Team and embed new processes and ways of working if required, to avoid duplication and to enhance the patient and family experience Complex Case Management Hold a case load of patients across South Kerrier. Prescribe within your individual scope of practice and ensure that prescribing is undertaken in a safe, cost-effective manner.