Job Description

To support the provision of clinical care for identified patients with frail and/or complex needs usually in their own homes in accordance with the patients care plan. To be supported by the ECT trained nurses but able to work with minimum direct supervision. To establish and maintain effective communications with patients, carers, and health professionals in a professional manner. To assist with ongoing support of patients, their families, and carers to manage their frailty and long-term health conditions.



To identify social isolation and loneliness, being proactive in signposting the ageing well population to relevant resources to empower patients to remain active and engage within their communities. To be able to identify and recognise a deterioration in an individuals health and act promptly to refer to relevant health professional to minimise the risk of rapid deterioration or where appropriate, avoid hospital admission. To have knowledge and understanding of the NEWS scoring format to assist with effective communication in acute/deteriorating presentations. In line with the PCN/ Practices Team policy, to update patient records ensuring entries are accurate, relevant, and timely and communicate care provided appropriately.



Following appropriate competency-based training, to undertake delegated clinical tasks and procedures such as, phlebotomy, ECG, bmi/bp readings, Urinalysis, diabetic foot checks. To support the facilitation of early discharge, where possible, from hospital for case managed patients by co-ordination of care and services to be delivered within primary care/community. To assist in the identification of those individuals with more complex health needs, with discussion with colleagues, refer for a holistic, multi-dimensional, interdisciplinary assessment with members of the MDT specialising in older peoples health, including a geriatrician. To participate in the MDT meetings, where appropriate.