Urgent Community Response Practitioner

Job overview

Due to the success of our Frailty Service, an exciting expansion and development opportunity has arisen. We are looking to recruit an enthusiastic and motivated Frailty Practitioner to join our dynamic team of dedicated Nursing and Medical Staff working in the Urgent Community Response (for patients 18yrs +), Ambulatory and Community Frailty and Frailty Virtual Ward.

The post holder will provide expert direct patient care, screen and identify the frail older patient in their own homes, in 24 hour care and in the acute trust. The successful candidates will help to improve pathways for patients who are experiencing an acute crisis and decompensating frailty in the community.

You will be responsible for delivering and supporting high quality care, act as an expert practitioner and a role model, offering a patient centred holistic approach to care planning and maximizing independence and well-being of those living with frailty.

The post holder will join a well-established team of Frailty practitioners, supported by Occupational Therapists, Physiotherapists and  Consultants.

Practitioners are working towards their Masters and supported by the Trust to do so, the successful candidate must have completed their Clinical examination and diagnostics.

Main duties of the job

KEY DUTIES

• Plan and manage complete episodes of care, working in partnership with others, and delegating and referring as appropriate to optimize health outcomes and resource use, as well as providing direct support to patients and clients.
• Use professional judgment in managing complex and unpredictable care events and capture the learning from these experiences to improve patient care and service delivery.
• To ensure that services are delivered effectively and efficiently against predetermined clinical performance targets.
• Conduct yourself and practice within an ethical framework based upon respect for the well- being and safety of patients and clients for the clinical case management of a defined population.
• The post-holder will collaborate with a wide range of statutory and voluntary organisations to maximise the nursing contribution in health improvement, planning and delivery of care to individuals, families and communities.
• In partnership with Consultant Staff, Consultant Nurse, Allied Health Professionals, and Head of Quality, develop robust governance systems by contributing to the development and implementation of evidence-based protocols, documentation processes, standards, policies and clinical guidelines through interpreting and synthesising information from a variety of sources and promoting own practice

Detailed job description and main responsibilities

CONTINUED KEY DUTIES

• Actively seek and participate in peer review of own practice.

• Enable patients/clients to learn by designing and coordinating the implementation of plans appropriate to their preferred approach to learning, motivation and developmental stage In partnership with Consultant Staff, Consultant Nurse, Allied Health Professionals, and Head of Quality, develop robust governance systems by contributing to the development and implementation of evidence-based protocols, documentation processes, standards, policies and clinical guidelines through interpreting and synthesising information from a variety of sources and promoting own practice

• Work in collaboration with others to plan and deliver interventions to meet the learning and development needs of own and other professions.

• Advocate and contribute to the development of an organisational culture that supports continuous learning and development, evidence-based practice, and succession planning; and have high-level communication skills and contribute to the wider development of those working in their area of practice by publicising and disseminating their work through presentations at conferences and articles in the professional press.

• Develop effective partnerships and positive working relationships with a variety of internal and external agencies to support seamless care provision across all agencies.

CLINICAL & PROFESSIONAL RESPONSIBILITIES

Maintain Professional Registration

Adhere to relevant Code of Practice of Professional body

Assess individuals, families and populations holistically using a range of different assessment methods, such as physical examination, ordering and interpreting diagnostic tests or advanced health needs assessment

Have a health promotion and prevention orientation, and comprehensively assess patients for risk factors and early signs of illness

Be able to draw on a diverse range of knowledge in decision-making to determine evidence-based therapeutic interventions (which will include prescribing, planning treatments, reviewing medication and actively monitoring the effectiveness of any interventions)

Prescribe and review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice and national and Trust protocols and formularies.

Work with patients and their carers in order to support compliance with and adherence to prescribed treatments.

Provide information and advice on prescribed or over-the-counter medication on medication regimens, side-effects and interactions

In the absence of Consultant, lead the co- ordination of care, working with partner agencies and key stake holders to ensure effectiveness of outcomes for defined case mix of patients.

Provide strategic clinical leadership in relation to area of specialty, working as an autonomous practitioner.

Lead the co-ordination of the care for people on a defined caseload, demonstrating advance competence in highly complex decision making, assessment and the management of clinical needs within specialist area of practice and refer to specialist services as appropriate.

Provide clinical leadership in workforce planning and skills profiling targeting resources to meet the needs of individuals, families and communities.

Undertake age appropriate physical and psychosocial assessment, interpreting core clinical and diagnostic findings in order to determine a diagnosis and develop an evidence-based plan of care.

Instigate therapeutic interventions and treatments aimed at improving health outcomes and promoting self-care, evaluate the effectiveness of interventions, modifying plans for optimal outcomes. Referring to Medical / Nurse Consultant where needed

Develop a knowledge of disease processes and consequences and provides specialist clinical advice to colleagues, individuals, families and communities.

Provide high level anticipatory care through the early identification of disease exacerbation in order to reduce the likelihood of acute illness, risks and prevent hospital admission.

Actively initiate and lead medicine management practice, review prescription, planning and adjustment of medicines, facilitating patients understanding to improve concordance with the support of their families.

Lead the development, maintenance and monitoring of service standards ensuring clinical and non-clinical practice interventions are based on the most recent evidence available and findings are incorporated into nursing practice.

Demonstrate advanced clinical and non-clinical interventions and act as an advisor and educator to colleagues and a variety of learners in area of specialty. Always working within scope of practice.

Supervise and teach learners in collaboration with education providers and other key stakeholders

Ensure expert knowledge, skills and competency are updated and maintained through appropriate CPD, training and development opportunities to enable effective care to be delivered in line with current research-based evidence and practice.

Ability to work autonomously, asking for help and advice when necessary

Ability to interact effectively with people who have different levels of communication skills

ADMINISTRATIVE RESPONSIBILITIES

To ensure that the recording of patient care is comprehensive, concise and in line with the NMC Record Keeping guidance

Ensure IT systems are current e.g., ADT to ensure that all patient information is confidential and is not disclosed to a third party except with permission of the patient or the Manager in Charge

To keep patient records up to date on a day-to-day basis following any interaction with patients/relatives

TEACHING & TRAINING RESPONSBILITIES

Improve quality and develop practice of clinical teams by sharing skills and knowledge both formally and informally.

Be proactively involved in developing strategies and undertaking activities that monitor and improve the quality of healthcare and the effectiveness of their own and others’ practice

Strive constantly to improve practice and health outcomes so that they are consistent with or better than national and international standards through initiating, facilitating and leading change at individual, team, organizational and system levels

Continually evaluate and audit the practice of self and others at individual and systems levels, selecting and applying valid and reliable approaches and methods which are appropriate to needs and context, and acting on the findings

Critically appraise and synthesize the outcomes of relevant research, evaluations and audits and apply the information when seeking to improve practice

Plan and seize opportunities to generate and apply new knowledge to their own and others’ practice in structured ways which are capable of evaluation.

Alert appropriate individuals and organisations to gaps in evidence and/or practice knowledge and, as either a principal investigator or in collaboration with others, support and conduct research that is likely to enhance practice

Use financial acumen in patient/client, team, organisational and system level decision- making and demonstrate appropriate strategies to enhance quality, productivity and value

Initiate and contribute towards research in area of expertise and critically appraise, evaluate and apply knowledge of theoretical frameworks, evidence and research findings within specialist area of practice.

Lead the development of service standards and policy and ensure compliance with legislation, policies and protocols and identify opportunities for the development of service.

Undertake strategic risk assessments and co-ordinate risk management plans that will safeguard protection of public and staff in line with policy.

Maintain contemporaneous and accurate clinical records, recording all patient related activity on the clinical systems /databases in accordance with NMC, national legislation and local and national standards.

LINE MANAGEMENT/SUPERVISORY RESPONSIBILITIES

Identify and implement systems to promote own contribution and demonstrate the impact of advanced level nursing to the healthcare team and the wider health and social care sector

Provide consultancy services to their own and other professions on therapeutic interventions, practice and service development within their field of expertise