Advanced Clinical Practitioner Frailty - Frailty Team
The post holder will work across the primary, community, secondary, and social care interface, providing advanced clinical assessment, diagnosis, treatment, prescribing, and proactive care planning for individuals living with frailty. You will respond to referrals from GPs, care homes, and wider Primary Care Team, undertaking comprehensive geriatric assessments and managing acute exacerbations of frailty-related conditions. You will also support the delivery of the Care Home Directed Enhanced Service, helping practices meet national requirements for frailty management and enhanced health in care homes. Key Responsibilities: Clinical Practice Deliver advanced clinical assessment and management of frail and complex patients. Make autonomous decisions on diagnosis, treatment, referrals, and prescribing. Conduct comprehensive frailty assessments using recognised tools (e.g., Clinical Frailty Scale). Undertake anticipatory care planning and support patients in managing their future health needs. Provide urgent care assessments for patients at risk of hospital admission or requiring supported discharge. Facilitate continuity of care through proactive post-discharge reviews. Leadership & Service Development Act as clinical lead within the Frailty Team, championing best practice and continuous improvement. Develop, implement, and review clinical protocols and pathways related to frailty care. Support quality improvement initiatives, service evaluation, and audits to improve outcomes. Contribute to the education, training, and clinical supervision of team members and students. Operational Management Participate in workforce planning, caseload management, and resource allocation within the frailty service. Engage in recruitment, appraisal, and performance management where appropriate. Analyse service data to support evaluation, reporting, and commissioning requirements. Communication & Collaboration Work closely with patients, carers, and the wider multidisciplinary team to ensure person-centred care. Lead or participate in MDT meetings, complex case discussions, and care home rounds. Build strong working relationships with GPs, social care, community providers, and local care organisations. Governance & Compliance Maintain professional registration and adhere to the NMC Code of Conduct. Ensure compliance with NHS policies, safeguarding, clinical governance, and information governance standards. Participate in incident reporting, risk management, and ongoing service governance processes.
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