Job Description

The Advanced Clinical Practitioner (ACP) in Frailty plays a pivotal role in the proactive management and care of older adults with frailty. The ACP will work collaboratively with multidisciplinary teams to assess, diagnose, plan, and deliver high-quality, patient-centered care to individuals living with frailty. This role focuses on preventing the deterioration of health, improving quality of life, and managing long-term conditions within the primary care setting. The ACP will conduct comprehensive assessments, including frailty screening, physical examinations, and reviews of medical histories, to develop personalised care plans.



They will be responsible for managing complex cases, ensuring appropriate interventions, and coordinating with healthcare professionals to support individuals across their care journey. Additionally, the ACP will have a key role in educating patients and their families about frailty, empowering them to make informed decisions regarding their health and well-being. The successful candidate will have advanced clinical skills, experience in geriatric or frailty care, and a strong commitment to improving outcomes for older adults in the primary care setting. They will demonstrate the ability to work autonomously while collaborating effectively within a multidisciplinary team.

Primary Duties and ResponsibilitiesPatient Care:

To work closely with the GPs, primary care and community staff in providing a service for patients ensuring the delivery of treatment, care planning and hospital admission prevention where appropriate. Undertakes first line comprehensive clinical assessment of patients, including those with complex presentations, employing an extended scope of practice beyond own profession including advanced clinical assessment skills, referral and interpretation of investigations and independent prescribing. To provide advanced assessment and care planning, including history taking and physical assessment of patients. To work closely with the consultant geriatricians, GPs and patients in identifying and devising effective care for each patient recognising them as an individual.



The plan of care, which should be developed in conjunction with the patient, carer/family and relevant others, should be outcome based and ensure appropriate pathways of care and communication via liaison and referral to other agencies as required. To work in conjunction with a wide range of clinical colleagues facilitating a patient or client focused, co-ordinated case management approach across primary and secondary care for people who are most vulnerable to and at high risk of repeat admissions to hospital To participate in efforts to shape multi-disciplinary pathways designed to support patient choice, improve quality of life, promote self-management and assure early intervention through the proactive provision of care in or as close to the patients own home as possible Requests, reviews and interprets diagnostic investigations within the context of other available information utilising a systematic process of clinical reasoning to formulate a differential diagnosis. Involves patients, families and carers in the identification of patient-centred concerns and priorities about health and well-being and negotiates approaches available to prevent deterioration or promote comfort and well-being. Demonstrates empathy and compassion when communicating sensitive information and advice to patients, carers and relatives.



Evaluates the effectiveness of therapeutic interventions and modifies the management plan accordingly. Adopts an integrated care approach to meeting an individual patients needs across services through collaboration with care teams who refer patients to the service and those who provide on-going care after discharge Assesses capacity, gains valid informed consent and works within a legal framework with patients who lack capacity to consent to treatment. Provides guidance to the clinical team with regard to therapeutic interventions, advance care planning and best interest decision-making for patients who lack mental capacity Recognises deteriorating patients, implements early interventions as needed and escalates care where appropriate. Empowers patients to manage their long-term conditions as independently as possible.



Applies expert knowledge in palliative care to symptom control, recognition of dying and advance care planning. Refers to other practitioners and agencies when necessary. Communication and Working Relationships: Ensure close liaison with GPs, clinicians, consultant geriatrician, and General Manager in communicating clinical issues Facilitates the communication of highly complex information regarding specialist issues on a range of service developments with the Practice and other health and social care professionals. This communication is directed to professional colleagues, across all areas of the health economy and primary care networks in the CCG area.



Advanced communication skills are necessary to communicate with patients to gain consent for treatment within a care pathway. Highly sensitive and confidential information is regularly required to be communicated to patients after clinical and medical results are collated, formulating specific management plans which can be upsetting in nature. Responsible for developing and maintaining effective communication channels with patient, carers and other health and social care professionals. Promote empathy, enable sharing of complex multi-professional viewpoints and sensitive handling of confidential information Analytical and Judgement: The ACP will work across the caseload using their clinical skills to identify the needs of patients and the correct services to liaise with.



Advise on the promotion of health and prevention of illness and provide information to individual and groups to prevent ill-health. To provide specialist assessment of patients, using analytical and judgement skills. To provide appropriate patient centred treatment using evidence based practice wherever possible. Analyses and interprets highly complex information gained during clinical examination and history taking to diagnose an individuals problems or illness and to decide on an appropriate course of action or treatment.



Analyses and interprets results from tests and investigations to inform diagnosis and treatment Able to access and assimilate previous patient records where available Identifies evidence based interventions to meet an individuals complex health needs within the context of the overall management plan Supports the development of a learning organisation by identifying, challenging and reporting poor performance and alerting managers to resource issues which may affect patient safety. Training and Development: Continuous Professional Education: Engage in ongoing professional development through formal courses, workshops, conferences, and e-learning to maintain and enhance clinical expertise in frailty care. Clinical Supervision and Mentorship: Provide clinical supervision, mentorship, and guidance to junior healthcare professionals, including nurses, trainees, and other allied health staff, fostering a culture of learning within the team. Knowledge Sharing: Lead and participate in training sessions, case discussions, and in-service education for the primary care team to raise awareness of frailty issues, management strategies, and best practice guidelines Role Development: Actively contribute to the development and expansion of the ACP role within the older persons team by identifying new learning needs and areas for service improvement.

Research and Evidence-Based Practice:

Stay up-to-date with the latest research, evidence, and best practices in frailty care, and incorporate these findings into both personal practice and team training initiatives. Collaboration with Academic Institutions: Build relationships with universities or training providers to facilitate learning opportunities for students or apprentices in frailty care. Audit and Quality Improvement: Participate in audits and quality improvement initiatives to assess the effectiveness of frailty management approaches and use the findings to inform training and development activities. Personal Reflection and Development Plans: Regularly review personal performance and clinical outcomes, setting development goals and seeking feedback from peers and supervisors to ensure ongoing professional growth.

Safeguarding:

Whitstable Medical Practice is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults; and expects all staff and post holders to share this commitment by understanding their role in effective safeguarding.