Frailty Matron

To provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission, or unnecessary length of hospital stay. Develop relationships with staff within the PCN, ICT, Complex Care at Home, Integrated Care Hub, Older Peoples Mental Health service, Rapid Response, adult social care, and the voluntary sector collaborating with them on a day-to-day basis. Undertake comprehensive assessment of the physical and psycho-social care needs of people with frailty who may also have complex chronic disease. This will involve using a single assessment process, gathering, and interpreting information, carrying out and ordering investigations and analysing the results alongside and with the support of GP colleagues. Establish an individuals functional capabilities with regard to frailty as well as any long-term conditions clinical management. Develop a person led evidence-based holistic health and social care plan in conjunction with medical and other health and social care colleagues, in partnership with patients and their relatives. Work collaboratively with colleagues and use the eFI/Rookwood frailty scoring system as well as the proactive whiteboard to actively seek out patients; identifying the early symptoms of frailty, disease exacerbation, acute illness, and injuries or who will benefit from clinical case management techniques to avoid unplanned hospital admission and reduce the length of hospital stays. Review patients with moderate to severe frailty who may be acutely unwell or whose condition may be deteriorating and formulate a management plan. Work autonomously to prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programmes of support as appropriate. Demonstrate a high level of clinical judgement. Facilitate discharge from hospital by co-ordinating care and services to be delivered within primary care, working in partnership with hospital ward staff, the integrated care team and other appropriate agencies, including the voluntary sector. Initiate and lead medicine management, reviews of medication and prescribe/deprescribe medicines and appliances for people via independent and supplementary prescribing arrangements. Establish and maintain excellent communication with individuals and groups, exploring complex issues relating to care options and decisions and sustain effective working relationships across all health and social care service organisations. Use a high level of communication and interpersonal skills to support and communicate effectively with patients, families and carers. Refer individuals to mental health and/or other services where appropriate. Enable individuals to access psychological support. Work proactively with people with frailty and their families to plan for and improve end of life care, ensuring that choices are reflected in personalised care plans and communicate with others involved in their care. Ensure patients needing palliative care are aligned to the Gloucestershire End of Life Strategy and NICE Clinical Guidelines. Challenge prejudice and inequalities in access to mainstream provision for individuals with frailty and may have long term conditions. Interpret and discuss assessment outcomes with people, carers, their GPs and other health and social care professions and the voluntary sector. Enable people to be as independent as possible by facilitating a range of self-management strategies through undertaking desired occupations and non- occupational activities including the support that is available from the voluntary sector. Be responsible for the co-ordination of weekly/fortnightly MDTs in each GP practice. Utilise knowledge and experience of Expert Patient Programmes and Self-Management Programmes to enhance both an individuals care pathway and the quality of service provided. Monitor quality and effectiveness of clinical care for people with frailty through audit and research. Accept responsibility for teaching professional colleagues, nursing auxiliaries, student nurses, people and carers. To fulfil the requirements for maintaining a professional registration. The post holder is expected to adhere to local policy and procedures. Confidentiality In the course of seeking treatment, Rosebank Health patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as confidential. Information relating to patients, carers, colleagues, healthcare workers or the business of the practice may only be divulged to authorised persons, in accordance with practice policies and procedures relating to confidentiality and the protection of personal and sensitive data. Health & safety Using personal security systems within the workplace according to practice guidelines. Practice and conduct themselves in such a manner as to promote a safe and efficient working environment. Identify and escalate any risks or safeguarding concerns to senior colleagues and actively seek to reduce or eliminate those concerns identified in a positive manner. Implement any directives from senior colleagues which seek to promote staff safety or reduce organisational risk. Embrace safeguarding mechanisms and support staff, patients and families during such as time when safeguarding principles may be applied. Equality and diversity The post-holder will support the equality, diversity and rights of patients, carers and colleagues by: Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights. Personal/Professional Development The post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development. Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work. Encouragement to develop and keep up to date with new services within the NHS. Quality The post-holder will strive to maintain quality within the practice, and will: Alert other team members to issues of quality and risk. Assess own performance and take accountability for own actions, either directly or under supervision. Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance. Work effectively with individuals in other agencies to meet patients needs. Effectively manage own time, workload and resources. Communication The post-holder should recognize the importance of effective communication within the team and will strive to: Communicate effectively with other team members Communicate effectively with patients and carers Recognize peoples needs for alternative methods of communication and respond accordingly Contribution to the implementation of services The post-holder will: Apply practice policies, standards and guidance. Discuss with other members of the team how the policies, standards and guidelines will affect own work. Participate in audit where appropriate. Safeguarding Rosebank Health is committed to creating and maintaining a safe and supportive environment for all individuals involved in our Practice. Safeguarding is a fundamental aspect of our organisation, and we prioritise the well-being and protection of children, young people, vulnerable adults, and all those who may be at risk of harm. As part of our commitment to safeguarding, all employees, volunteers, and contractors are expected to share this commitment and adhere to the Practices safeguarding policies and procedures. We strive to ensure that everyone associated with Rosebank Health understands their responsibility to identify and report any safeguarding concerns promptly.

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