Patient Care & Clinical Management: Undertake holistic frailty assessments, including history taking and simple investigations Recognise and act on situations potentially detrimental to patient health and well being. Provide ongoing management of long-term conditions such as diabetes, COPD, hypertension, and cardiovascular disease. Support and advise patients on health promotion, illness prevention, and self-management. Support in the development of Advance Care Planning Deliver nursing treatments in collaboration with GPs or independently within agreed protocols.
Perform health screenings within agreed protocols, referring to GPs as necessary. Provide appropriate signposting to other clinicians or external organisations while ensuring ongoing care. Ensure proactive and early case management to prevent unnecessary hospital admissions/readmissions. Maintain accurate documentation within GP online systems (EMIS, SystemOne).
Communicate complex or sensitive information effectively to patients and carers, recognising barriers to understanding. Maintain effective communication with GP practices and other healthcare teams. Team & Service Development: Support and guide HCAs and SPLWs as required. Contribute to the development and continual improvement of the PCN Frailty Team.
Ensure care is evidence-based and aligns with local policies and procedures. Maintain professional competency and remain up to date for NMC revalidation. In addition to the primary responsibilities, the frailty nurse may be requested to: Participate in audit work, effectively utilising the audit cycle Participate in local initiatives to enhance service delivery and patient care Support and participate in shared learning within the practice Continually review clinical practices, responding to local and national policies and initiatives where appropriate Participate in the review of significant and near-miss events applying a structured approach, i.e. root cause analysis (RCA)