General Practice Assistant - Frailty Team

This is an exciting new role designed to support the work of Weymouthand Portland Frailty Team.

Weymouth and Portland Frailty Team is well established and has been expanding since April 2015 to provide proactive holistic care for complex frail patients who are living in care homes or housebound and has also established an Ageing Well Clinic in 2022. This team is led by a General Practitioner and hasa team of Frailty Practitioners who are Nurses, Advanced Clinical Practitioners, paramedics, Occupational Therapist, physiotherapist and are supported by a Frailty Care Coordinator and 3 Frailty Health Care Assistants.

There is a focus on ongoing case finding using risk profiling measures (EFI) and population health management (DiiS).

The main aims of the Frailty service are to -

• Deliver EHCH (enhanced health in care homes)
• Provide proactive, routine assessments based on a Comprehensive Geriatric Assessment to patients living in their own homes
• To make timely referrals to the wider multi-professional team to improve overall wellbeing reduce risk of falls, reduce risk of deterioration and reduce risk of hospital admission.

To complete Personalised Care and Support Plans, focusing on what matters most to the patient

To proactively identify patients who would benefit from a holistic assessment

To support Ageing Well in the community, with a focus on reducing the progression of frailty / reversing this where possible

To assess patient who have been re-referred with frailty related decline

Effective team work to ensure the right patient is seen by the right staff member at the right time

You will need outstanding people skills, a caring nature and good IT skills with a desire to learn in this ever-changing environment.

An ethos of promotion of independence, personalisation and partnership-working is integral to this role.

Essential attributes for the role are as follows -

• Excellent communication and interpersonal skills
• Good team working skills
• Self-motivated and able to work on own
• Good organisational skills

Two Harbours Healthcare is a not for profit organisation led by local General Practices in Weymouth and Portland. Our goal is to work more closely together (and with stakeholders) to share expertise, resources and provide services for the NHS.

The purpose of the role is to support the day to day running of Weymouth and Portland Frailty Team as follows -

• Support with information gathering for new referrals this will involve making telephone calls to the patient and or their relatives carers and seeking further information to enable to allocation and prioritisation of the patient
• Support with information gathering for re-referrals this will involve making telephone calls to the patient and or their relatives carers and seeking further information to enable to allocation and prioritisation of the patient
• Work closely and in partnership with PCN colleagues including Social Prescribing Link Workers, Health Coaches and Clinical Pharmacist(s) handing over to these teams when appropriate
• Make follow up phone calls to identified patients to review progress and feed back to senior clinical staff
• Arranging follow up
• Supporting with recall management
• Support with risk profiling, including data and searches
• Use Population Health Intelligence and Risk Stratification tools proactively to identify groups of patients for MDT discussions or to deliver health services
• May attend MDT meetings and support with referral management
• Opportunity to develop and shape this service

Perform any duty specifically delegated by your line manager as being properly the responsibility of this post.

The tasks and responsibilities in this job description may change in the light of developments within the PCN and are subject to review.

• Understanding and adherence to strict confidentiality
• Excellent communication and interpersonal skills, both written and verbal
• Good team working skills
• Able to analyse & extract relevant information
• Good organizational skills
• Able to use own judgement, resourcefulness and common sense
• Able to work under pressure
• Able to…