Specialist Ageing Well Practitioner

Job overview

We seek a dedicated and skilled Specialist Ageing Well Practitioner to join out Proactive Ageing Well Service (PAWS) until March 2027. The purpose of the service is to proactively assess those living with frailty, complete the medical and specialist nursing domain of the Comprehensive Geriatric Assessment and create patient centred plans of care, ensuring the person is linked into the wider community MDT in order to improve symptoms of frailty, reduce disease burden and avoid unnecessary admissions to hospital.

Main duties of the job

The purpose of the Ageing Well Practitioner role is to deliver comprehensive assessments and support to older adults within the community as part of the Proactive Ageing Well Service (PAWS). The practitioner will use case finding tools and pre-assessments to identify those who would benefit most from proactive Comprehensive Geriatric Assessments (CGA) to ensure they receive coordinated care from the wider community multidisciplinary team (MDT). By determining patient priorities and commencing future care planning, this role aims to prevent unnecessary hospital admissions and maintain care in the individual's preferred environment. This position is integral to enhancing the quality of life for older adults through proactive, preventative, and patient-centred care.

Detailed job description and main responsibilities

Expert Clinical Practice:

• Identify older adults who would benefit from proactive Comprehensive Geriatric Assessment (CGA) within the borough of Lewisham;

• Provide a level of enhanced and comprehensive geriatric assessment, based on a specialist body of knowledge. To appropriately assess, examine, investigate, diagnose and treat patients, resulting in safe management and appropriate referral

• Order and interpret investigations and act on results with appropriate supervision.

• Manage patients within own case load and present care plans to the MDT.

• Carry out comprehensive medication reviews and make suggestions for changes in conjunction with the person’s GP (if in possession of prescribing qualification).

• Take the lead in advance care planning conversations, ensuring that patients and their families understand their options, uncover their goals and work with the patient and family towards achieving them.

• Provide education and support to patients, families, and caregivers about managing conditions associated with co-morbidities and ageing utilising  community resources when it falls outside the scope of the PAWS scope.

• To contribute to the development and improvement of systems and processes that facilitates patient flow

• To improve the quality of the patient experience by identifying and meeting the individual clinical needs of patients
• To rigorously review all aspects of the patient’s care plan and identify and address issues that may result in a sub-standard service

• Contribute to the review and development of integrated care pathways and clinical guidelines to ensure a standardised approach

• Practice with confidence and competence within your professional guidelines and code of conduct (NMC/HCPC/GPhC).

• Maintain own clinical development by keeping abreast of new treatments and technologies within frailty and older persons care

• To ensure that accurate documentation and records of patient care are kept.

• Ability to adapt specialist clinical knowledge and skills to different clinical settings and influence service delivery and patient care

• Actively participate in effective systems and processes for infection control management and relevant audit within the clinical area

• Utilise and demonstrate highly sensitive communication styles, to ensure patients are fully informed and consent to treatment.

• Communicate patient’s conditions verbally and in writing to other members of the health care team and contribute to the decision-making processes in patient management. Act as an advocate for patients and colleagues.

• Ensure awareness of sources of support and guidance e.g., patient liaison service, and provide information in an accurate format to all patients.

• Be able to anticipate barriers to effective communication and take action to improve communication.

Management and Leadership:

• Participate in the development of the PAWS team and act and facilitate change with an innovative and adaptable approach

• To contribute to evidence-based policies and procedures specifically required by the PAWS team

• Maintain effective communication with the multidisciplinary team to ensure high standards of care

• To work collaboratively with representatives of other clinical areas, disciplines and services to provide a seamless pathway of care
• To be conversant with all Trust policies and procedures to represent the Trust at specialist forums.

• Adhere to confidentiality at all times with sensitive personal data
• Prioritise, organise and manage frailty workload.

Education and Practice Development:

• To help identify, plan and implement goals for clinical development of staff working within the PAWS team

• To reflect and discuss areas of practice with senior service lead and Community Geriatrician.

• To participate in teaching programmes for nursing, medical and allied health professional staff of all grades.
• To maintain close links with higher education and to participate in the development and delivery of new and established specialist older adult  practice programmes.

• To exhibit a personal commitment to clinical education and development.

• Participates in shared learning across the division and wider organisation.

Service Improvement and Performance:

• In collaboration with the MDT participate in PAWS service development and projects

• To work with administrative and clinical staff to achieve sustained improvements, including in the following areas: clinical quality, patient satisfaction and meeting local and national targets

• Participate in service improvement initiatives and associated work streams to support specific patient pathways.

• To ensure that the services meet pathway targets

Audit and Research:

• Contribute and assist in the development of multidisciplinary research and clinical audit in a frailty setting

• Participate and contribute to any on-going regional and national research to evaluate the effectiveness of care strategies related to the patient experience

• To share best practice; through publications and attendance/presentation opportunities at conference level

Resource Management

• To apply sound financial evaluation to proposed service developments.

• Maintain accurate records in relation to equipment used.

Risk Management

• To ensure that the systems are in place to manage, reduce and prevent clinical risk to self and others.

• To monitor incidents highlighted by members of the team and communicate to appropriate areas to address risk issues.

• Promote best practice in health and safety, in line with Trust policy.