Core Responsibilities
* To provide clinical, educational and strategic support to the team, including clinical skills development and knowledge tutorials
* To work in partnership with the Consultants and GP in Older Person's Medicine to establish an integrated frailty management system
* To work in partnership with the leadership teams for Community Nursing and Therapies to support the development of the reactive team responding to frailty crisis in the community, preventing unnecessary hospital admission
* To work in partnership with integrated neighbourhood teams including primary care networks and the leadership teams for Community Nursing and Therapies to support the development of the proactive team preventing frailty crisis in the community
* Facilitate and support early discharge for inpatients where possible
* Involvement in the development of proactive care service
* Provide senior clinical decision making to the team
* Develop networks with key stakeholders
* Provide pastoral support, mentorship and educational training in the management of frailty to staff within the healthcare economy
* Daily ward round/board round
* Continuity of care for patients and colleagues – same doctor each day for a run of preferably 3 days with handover of complex cases to out of hours staff and to the doctor taking over a run of shifts
* Discussion of cases with clinical staff who visit patients
* Patient visits
About the Organisation
Our ambition is to become the place of choice for acutely ill frail patients with increasing access to diagnostics and home interventions, working in a collaborative, integrated, fluid approach to providing healthcare in the community rather than static bedded care. In addition to this we are developing a strategy for proactive care, and these post holders will be key to its development, focusing on delivering proactive care to the most complex and vulnerable patients with the aim of reducing avoidable exacerbations of ill‑health and improving the quality of care for older people.
Hospital@Home Service
The lead decision maker post holder will work in partnership with our Lead GP and the multi‑disciplinary team (MDT) to grow the 'Hospital@Home' service, a frailty virtual ward serving frail people in Middlesbrough, Redcar and Cleveland, and working in partnership with North Tees for patients in Stockton and Hartlepool and the wider health and social care system.
Equality, Diversity and Inclusion
South Tees Hospitals NHS Foundation Trust is committed to promoting equality of opportunity, celebrating and valuing diversity and eliminating any form of unlawful discrimination across our workforce, ensuring our people are truly representative of the communities we serve. All individuals regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation are encouraged to apply for this post. We welcome applications from the Black and Minority Ethnic (BAME) Network, LGBT+ Network, Disability and Long‑Term Health Conditions Network, Faith Network, Childless not by Choice Network and the Menopause Support Group.
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