Advanced Clinical Practitioner - Frailty

We are looking for a motivated and experienced Advanced Clinical Practitioner to work within our Frail Elderly Assessment Team (FEAT). This is an exciting opportunity to deliver high quality patient-centered care to frail patients in their own homes and in our care homes. The role combines autonomous practice, care coordination, multi-agency collaboration, management of increasing frailty, dementia and end of life care.

The postholder will work at an advanced level of clinical practice, exercising a high degree of professional autonomy and accountability while working within the NMC code and national ACP frameworks.

• Provide expert management of complex frailty syndromes, dementia, delirium, polypharmacy, falls risk and end of life needs.
• Exercise advanced clinical reasoning to assess, diagnose, treat, and manage patients without direct input from a medical practitioner, recognising own professional boundaries and seeking senior clinical support when required.
• Monitor medication use and adjust treatment plans working autonomously as required
• Escalate concerns appropriately
• Work closely with GPs, OTs, Physiotherapists, Care Co-ordinators, Social Prescribers and Community Nursing Team
• Support patients and families in understanding and managing frailty
• Promote lifestyle and self management strategies
• Conduct regular care plan reviews
• Identify patients in need of palliative support and facilitate advanced care planning discussions
• Communicating with distressed patients and relatives
• Caring for patients and relatives following receipt of bad news
• Communicating and caring for patients who have reduced understanding and insight due to cognitive impairments
• Participate/lead weekly enhanced care home reviews
• Undertake daily acute care home visits requested through our clinical triage system identifying clinical emergencies, deteriorating patients or patients at risk of deterioration
• Participate in regular clinical supervision
• Work using FEAT and champion evidence-based interventions
• Conduct comprehensive geriatric assessments using appropriate tools

NCPC (North Cumbria Primary Care) was established in August 2019 in response to an increasingly fragile general practice provision within North Cumbria. NCPCs vision is to bring practices together to develop a sustainable, fully integrated primary care- built locally and delivered together. The Copeland NCPC area consists of 3 major practices, Fellview Health Care, Lowther Medical Centre and Seascale Health Centre as well as a shared PCN (Primary Care Network) which delivers services to patients across all 3 practices.

We are a not-for-profit company with all money we receive in funding and other business activities going towards supporting the organisation, our staff, and our services.

Main Duties and Responsibilities

• Provide expert management of complex frailty syndromes, dementia, delirium, polypharmacy, falls risk and end of life needs.
• Exercise advanced clinical reasoning to assess, diagnose, treat, and manage patients without direct input from a medical practitioner, recognising own professional boundaries and seeking senior clinical support when required.
• Monitor medication use and adjust treatment plans as required, autonomously working within scope of practice and in line with prescribing competencies.
• Escalate concerns appropriately and initiate urgent or emergency interventions when required.
• Identify when clinical presentations fall outside of scope of practice and elevate appropriately to GP or senior clinicians.
• Work closely with GPs, Occupational Therapists, Physiotherapists, Care Co-ordinators, Social Prescribers and Community Nursing Team
• Attend the MDT meetings and case reviews
• Support patients and families in understanding and managing frailty
• Promote lifestyle and self management strategies to optimise health and independence
• Functions at a high level to carry out clinical decision making such as diagnosing and managing patients without input from a medical practitioner remaining within scope of a professional practice.
• Functions at a high level in relation to communication skills through patient consultation and nursing assessment of physical, psychological and social needs.
• Completing proactive, individualised clinical management plans for care home residents improving their health experience and reducing unnecessary and potentially harmful hospital admissions
• Conduct regular care plan reviews
• Identify patients in need of…