Job Description

Based on an integrated approach, the Frailty Practitioner will join the existing team, working in an integrated way with the wider MDT which currently exists in the locality to provide a pro-active service for the frail population. The Frailty Practitioner will be part of the primary healthcare multi-disciplinary team and will utilise the skills of the wider existing primary care team. Housebound Patients: Home visits to identified patients to complete baseline assessments using an agreed proforma CGA template to include (but not exclusively) continence, skin, nutritional status, care needs and unmet needs. Referral of patients when appropriate to Frailty Assistants to collect additional information or to complete additional assessments e.g., weight monitoring, BP checks, ECG, phlebotomy etc Follow up visits to patients who are appropriate for the service (i.e., moderate, or severe frailty) to identify deterioration, chronic disease monitoring, referrals for newly identified needs Ensure patients who are discharged from the service (mild frailty or less) are aware they can re-refer if deteriorating Make referrals to the wider MDT (including third sector) if and when appropriate Following assessment and diagnosis; develop and communicate clinical management plans Liaise with usual GP if assistance required for management strategies Work with the lead GP to help develop a proactive review register ensuring that Lead GP is aware of patients assessed and outcome of assessments Manage own caseload of patients determine appropriate frequency for review, schedule appointments Days and hours to be negotiated, no unsociable hours required.



Awareness and understanding of the supporting document Housebound visiting model specification Care Home Service Weekly visit to named care homes To assist with cross cover within the team to ensure each care home receives a weekly visit (following a set rota) To assist with triage for acute care home visits (following a set rota) Review patients as requested by the care home, by task from Lead GP or other colleagues, monitor patients for deterioration, chronic disease monitoring Make referrals to the wider MDT (including third sector) if and when appropriate Ensure Lead GP is notified of all new patients Formulate diagnosis, develop, and communicate clinical management plans Liaise with Lead GP if assistance required for management strategies Identify patients approaching end of life, support care home with planning, prescribe anticipatory palliative medication, liaise with Lead GP for face-to-face review. Awareness and understanding of the supporting document Care Home visiting model specification Verification of Life Extinct For all patients Advance Care Planning discussion to include discussion about resuscitation status Completion of the Dorset Care Plan Completion of Allow a Natural Death Form when appropriate Ensure awareness of recall system and when reviews are due, follow-on recalls and ensure all relevant monitoring is completed Holistic Medication review Prescribing and appropriate adjustments of medication with appropriate monitoring Other Attendance at surgery MDT meetings if requested to do so Comprehensive record keeping on SystmOne Ensure work emails are regular accessed Ensure work mobile is carried at all times and that messages are picked up at regular intervals through the working day Interpret data from various sources e.g., frailty data, MDT data, frailty registers to determine which patients would benefit from holistic review when requested to do so Assist Lead GP when requested to develop service