Older Persons Health Practitioner

Job summary
Are you an enthusiastic, experienced clinician with an interest in older peoples health and frailty, looking to expand your skills further?

A new opportunity has arisen for a compassionate Older Persons Health practitioner to join the Mewstone PCN Team. You will work as part of a multidisciplinary team responsible for providing a comprehensive care for older people both in community and care home settings.

Our main objectives are to improve care quality and coordination, increase the use of anticipatory care plans, reduce falls, improve the management of long-term conditions and to avoid unnecessary hospital admissions.

The individual will be expected to ensure the safety and wellbeing of service users and always work in a manner that promotes dignity and improved patient experience through the adoption of person-centred care principles.

Main duties of the job

• To evaluate, prioritise patients symptoms, provide general advice and reassurance in line with the Standards for Better Health and up to date clinical research guidelines.
• Provide assessment, screening and treatment services and health education advice to our older patient population including housebound patients, those with severe frailty and care home residents.
• To play a pivotal role in Ageing Well MDTs.
• To provide appropriate signposting to the relevant clinician or external organisations.
• To visit patients at home and within care homes as part of the wider clinical team.
• To support and advise patients on the promotion of health, prevention of ill-health and the self-management of their health within their limitations
• To work in conjunction with GP leads including Care Homes to: Preparation of acute prescriptions for caseload. Health promotion. Individual care planning. Proactively manage and treat long term conditions, in line with national, local and practice policy and protocols. Completion of home visits to patients on case load

About us
Our vision is to empower older people to experience better wellbeing, stronger social connections and greater freedom from frailty. We will work alongside colleagues and patients to promote healthy aging and support independence in later years. We will make decisions with patients, not about them, even if care needs become numerous and complex. Committed to making the best use of NHS resources, we will encourage one another to continually learn, reflect and improve the care we provide. Through curiosity, kindness and thoughtfulness, we will be a trusted and effective team that people always enjoy working with.

Mewstone Primary Care Network has a list size of approximately 32,000 patients. The PCN practices are Church View Surgery, Dean Cross Surgery, Wembury Surgery and Yealm Medical Centre. The four practices share the same ethos of supportive learning and all provide placements for doctors in training. We are looking to expand further as a learning organisation.

You will work alongside our GPs, nursing teams, administrators and extended workforce including clinical pharmacists, pharmacy technicians, first contact physiotherapist, mental health practitioners, social prescribing link workers, and care co-ordinators.

All network practices are high achieving practices with a commitment to mentoring and supporting their staff.

Job responsibilities
Older people need personalised care which is often managed by multiple different health and social teams. They report finding the systems difficult to access and to challenging to navigate. It is important that people living with frailty have access to proactive, joined-up care to maximise health and wellbeing and prevent problems arising in the first place. Equally important is access to rapid, specialist services in the event of a health crisis.

Our aim is for the healthcare of the patient to flow seamlessly between health and social teams supporting patients to have more choice, independence, and resilience, ensuring patients are able receive early intervention, plan their care and experience quality joined up services that work for them

Based on an integrated approach, the Older Persons Practitioner will join the existing team, working in an integrated way with the wider MDT in the PCN to provide a pro-active service for the older population.

The Older Persons Practitioner will be part of the primary healthcare multi-disciplinary team and will utilise the skills of the wider existing primary care team.

Main Duties and Responsibilities

• To complete the requested assessments for registered patients allocated to the team and maintain appropriate records of treatment given and NHS services provided; When appropriate, to make a relevant diagnosis and management plan, implement this plan and subsequently evaluate it.
• Carry out consultations and physical assessments as requested, formulate a diagnosis and maintain high quality contemporaneous records using SystmOne (mobile working will be facilitated with personal laptop and internet connection).
• The post-holder will make him/herself available to undertake visits to housebound patients and nursing homes as requested, assessing patients, liaising with the service GPs or registered GP.
• The post-holder will play a pivotal role at Ageing Well MDT meetings where possible.
• Liaise with other members of community teams, as appropriate to individual patient needs.
• Arrange for the referral of patients when it is possible for the practitioner to make the referral, otherwise defer the need for a referral back to the GP.
• Note any possible issues with medication compliance identified during any patient contact and proactively liaise with the PCN Prescribing Team.
• Actively work with the wider MDT by working with, but not exclusively, the community matrons, community nurses, discharge co-ordinators, elderly care teams and community hospitals, dieticians, tissue viability team, CPN, CRT, physio, SALT, falls prevention services.
• Be prepared to make clinical judgement based on either provided data and noted review or both to reach a conclusion regarding whether a patient needs to be assessed by the team.
• Evaluate MDT data to determine the need for patients to be reviewed by the team.
• Maintain appropriate levels and means of communication i.e. mobile phone, professional email
• Clinical governance will be provided by the Clinical Director, GP partners and the lead GPs.
• Training opportunities can be discussed when appropriate.

Professional Responsibilities

• Have awareness of, and compliance with, all relevant PCN and Practice policies/guidelines e.g. confidentiality, data protection, health and safety, safeguarding etc.
• Provide regular feedback to the GP(s) within the service.
• Maintain high standards of personal accountability
• Required to effectively communicate with older patients and their families, other team members, doctors and other hospital staff in the course of the duties.
• Contribute to evaluation/audit of the project and clinical standard setting within the team including collecting data for audits.
• Participate through individual performance review, in matching organisational aims with personal objectives.
• At all times provide a caring service and to treat those with whom they come into contact in a courteous and respectful manner.
• Demonstrate their commitment by their regular attendance and the efficient completion of all tasks allocated to them.
• Adhere to Equality and Good Relations duties throughout the course of their employment.
• Ensure the ongoing confidence of the public in-service provision
• Carry out such duties as may be reasonably required
• To ensure practice is evidence based and high quality and to acknowledge personal limitations ensuring patient safety remains paramount.
• Have an awareness of the desired project outcomes, and work towards fulfilling these.

Person Specification
Qualifications

• Registered Nurse or Allied Health Care Practitioner.
• Completion of history taking, physical examination course and prescribing.
• Membership of the relevant Professional body.
• Evidence of recent professional development in an up-to-date portfolio
• Experience at Nurse or Practitioner equivalent of Band 6 and above.
• Experience of working with older adults living with frailty.
• Experience of managing change.
• Demonstrable knowledge of assessment and therapeutic interventions in area of specialism.
• Experience of developing specialist programmes of care for an individual or groups of patients and of providing highly specialist advice.
• Able to demonstrate specialist clinical reasoning skills to assimilate information in order to make a clinical judgement regarding diagnosis and intervention.
• Ability to prioritise and organise workload effectively.
• Able to analyse data and produce reports using Microsoft Excel and Word.
• Experience of using electronic patient and service user record systems.

Desirable

• Recent previous experience within a comparable role in the community.
• Able to effectively manage available resources in the pursuit of quality service provision ensuring a safe environment.
• Experience of working in a primary care environment
• Experience of chronic disease management
• Post graduate diploma or degree in primary care
• Independent prescriber
• Knowledge and understanding of NHS Strategy relevant to role

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Applicants must have current UK professional registration. For further information please see NHS Careers website.