PCN Frailty Team Nurse

Job Summary

We are recruiting a Frailty Practitioner to join our developing PCN. This is an exciting time to join our PCN as the successful candidate will have the opportunity to help shape the service alongside the Lead GP. We are looking for a highly skilled healthcare practitioner responsible for delivering proactive, personalised care to individuals living with frailty in community settings. This role interfaces with primary, secondary, social care and VCSE organisations, ensuring holistic management of frailty.

With a focus on prevention, the role is pivotal in the delivery of the NHSE Proactive Care Framework at PCN level for people living with moderate or severe frailty, working collaboratively with multi‑agency multi‑disciplinary teams (MDTs) and system partners to enhance independence and quality of life and in turn reduce the risk of unplanned hospital admissions. A key element of the role is to work with people living with frailty in a strength‑based, collaborative way that focuses on what matters to them.

Although there may be some opportunities to work from home, you must be prepared to work across various locations in the Forest of Dean and occasionally may be required to attend GDOCs offices in Gloucester.

Approx. 20 hours per week. Applications may close early depending on response.

• Moderate and Severe Frailty
  • Case Identification using eFI/Personal Proactive Whiteboard
  • Triage patients and complete a comprehensive geriatric assessment (CGA) where appropriate
  • Producing Personalised Care and Support Plan (PCSP) and agree with patient/Carer
  • Dementia Co‑diagnosis
  • Coordinate and lead MDT meetings
• General
  • Leadership and support to the Care Coordinator and Frailty Team Administrator
  • Clinical assessment, diagnosis, and case management of people living with frailty in the community using agreed standardised tools and templates
  • Support the development of frailty awareness and skills for other practitioners, carers, and patients
  • Contribute to the design, implementation, and evaluation of frailty pathways and services
  • Identify and manage clinical risks
  • Collect and analyse data to support risk stratification, use of the Personalised Proactive Whiteboard, and monitor outcomes
• Coordinated and Multi‑Professional Working
  • Ensure close multi‑professional and multi‑agency working, especially with the local Integrated Neighbourhood Team(s), to facilitate the delivery of each patient’s PCSP
• Continuity of Care Including Reviews
  • Support the Care Coordinator to ensure regular review of patients takes place as planned and agreed according to the individual needs of the person and/or following trigger events such as hospital admission
• Leadership and Partnership Working
  • Provide clinical assessment, diagnosis and case management of people living with frailty in the community using agreed standardised tools and templates
  • Build and maintain effective working relationships with GPs, acute and community hospitals, Adult Social Care, voluntary sector organisations and other community services to deliver integrated care
  • Ensure seamless transitions of care and continuity through proactive case management and liaison with all relevant stakeholders
  • Lead and participate in MDT meetings, ensuring collaborative care planning and shared decision‑making across system partners
• Education, Service Development and Risk Management
  • Support the development of frailty awareness and skills for other practitioners, carers and patients
  • Contribute to the design, implementation and evaluation of frailty pathways and services
  • Identify and manage clinical risks, including falls, polypharmacy and cognitive decline
• Data and Audit
  • Collect and analyse data to support risk stratification and segmentation of the patient cohort, enable use of the Personalised Proactive Whiteboard for care coordination, monitor outcomes and measure impact, support quality improvement and inform commissioning conversations
• Other Responsibilities
  • Applying PCN policies, standards and guidance
  • Contributing to the teaching and training of trainees, new employees and employees who are undertaking training
  • Awareness of and compliance with all relevant G DOC…