As part of our focus on frailty and a move towards proactive care, Synergy Health PCN is looking for a community frailty clinician. The main focus will be on frail patients who currently live in their own homes, with proactive reviews trying to identify patients at high risk and reducing their chances of admission to hospital. There will also be work done around those patients who have had recent admissions to reduce their risks of readmission.
Working as part of the wider MDT alongside the frailty lead GP, Community Consultant Geriatrician, PCN care coordinators and other community teams, this is an excellent opportunity for a clinician with an interest in frailty.
Whilst this role has previously been carried out by an advanced nurse practitioner, the key criteria is an interest in frailty and improving proactive approaches to healthcare. As such, applications would also be considered from GPs with an interest in frailty and practice nurses who wish to upskill into this area, with training support available for the right candidate. This is an exciting opportunity to deliver care to frail patients in their own homes and across our 3 practices.
Main duties of the job
Core Duties
Conduct comprehensive geriatric assessments using appropriate tools.
Monitor medication use and adjust treatment plans as required.
Work closely with GPs, Occupational Therapists, Physiotherapists, Care Coordinators, Social Prescribers and Community Nursing Team.
Attend and lead the MDT meetings and case reviews.
Support patients and families in understanding and managing frailty.
Promote lifestyle and self‑management strategies to optimise health and independence.
Functions at a high level to carry out clinical decision‑making such as diagnosing and managing patients without direct input from a medical practitioner remaining within scope of a professional practice.
Functions at a high level in relation to communication skills through patient consultation and nursing assessment of physical, psychological and social needs.
Identify patients in need of palliative support and facilitate advanced care planning discussions with patients and families.
Communicating and caring for patients who have reduced understanding and insight due to cognitive impairments.
Undertake acute home visits requested through our clinical triage system identifying clinical emergencies, deteriorating patients or patients at risk of deterioration ensuring appropriate action.
About us
Primary Care Networks (PCN) are local neighbourhoods where all health and social care services work together to deliver a better experience for their citizens.
Synergy Health PCN covers three practices in Gedling Borough, Jubilee Park Medical Partnership in Carlton with a branch site in Lowdham, West Oak on Westdale Lane, Mapperley and Trentside Medical Group in Netherfield and Carlton.
We are a standalone PCN with a lead practice and have a population of 36,000 patients.
The PCN has care coordinators, social prescribing link workers, advanced nurse practitioner care homes, first contact physios and clinical pharmacists. These roles will work closely together to develop and grow the PCN and improve patient care across our patient list.
Our vision is to build and develop collaborative working across member practices and stakeholders, to support and strengthen the delivery of Primary Care services and improve health outcomes for the local population we serve.
Disclosure and Barring Service Check
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.
£55,690 to £62,682 a year dependent on experience
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