Advanced Clinical Practitioner Discharge to Assess (Pathway 2)
The Discharge to Assess (D2A) Pathway 2 wasacquired by the Fuller and Forbes Partnership 18 months ago.
We are looking for applicants whowill work alongside a team of GPs todeliver high-quality, patient-centered clinical care to individuals dischargedfrom hospital into a Pathway 2 Discharge to Assess placement and who requireshort-term support & assessment of needs in a bedded rehabilitationsetting.
Main duties of the job
The ACP will operate autonomously, managing full clinical episodes, assessingpatients on registering with the service, managing periods of chronic or acuteillness, diagnosing conditions, prescribing treatments, coordinating ongoingcare, and supporting discharge planning. This role is crucial to ensuringtimely, effective transitions of care from hospital to community and eventuallyto home or long-term care.
About us
Recently acquired by the Fuller and Forbes partnership,the DTA team is part of Mayflower Medical Group which is a collection of 5 GP Surgeries based across Plymouth. Our surgeries provide healthcare to 35,000 patients at the following locations Stirling Road, Ernesettle, Trelawny, Mannamead and Mount Gould.
As a group, our vision is to enable patients to live longer and healthier lives that are full, active and meaningful. We aim to do this by developing a sustainable primary healthcare service. Our service is undertaken by our vast multidisciplinary team of GPs, Advanced Clinical Practitioners, Pharmacists, Paramedics and Nursing teams, as well as our PCN staff.
Job responsibilities
Key Responsibilities:
- Provideadvanced assessment and clinical decision-making for potentially unstable patientsnewly transferred to D2A Pathway 2 beds.
- Responsible for the assessment &treatment of both, physical and mental health needs of the individual.
- Develop, initiate, and evaluate treatment plans and prescribing (ifqualified).
- Monitor and respond to changes in patient condition, escalatingappropriately.
- Collaborate with external multidisciplinary teams including physiotherapists,occupational therapists, social care teams, and discharge coordinators.
- conduct clinical reviews within the D2A setting.
- Support timely, safe discharge decisions and onward referrals.
- Undertake comprehensive initialassessments (CGA), ensuring accurate documentation and risk stratification.
- Create personalised care plans and ensure effective communication with DTAbedded providers.
- Facilitate safe discharge planning in collaboration with external providers, families,reablement teams, and social services.
- Act as a senior clinical leader withinthe D2A GP Service.
- Support the development and refinement of D2A care pathways to enhance flowand patient outcomes.
- Contribute to rota development and clinical cover planning.
- Participate in service audits and outcome tracking.
- Provide supervision, clinical mentorshipand pastoral support to other team members.
- Deliver informal and formal teaching on assessment and care planning in D2Asettings.
- Participate in audit and qualityassurance projects, particularly around readmission prevention and dischargesafety.
- Implement evidence-based interventions to improve outcomes and reduce lengthof stay.
Person Specification
Qualifications
* - Registered Nurse, Paramedic, AHP or other regulated profession, with Advanced Practice MSc or equivalent.
* - Independent prescriber.
* - Significant clinical experience in primary care, acute care,
* rehabilitation, intermediate care, or complex discharge pathways.
* - Strong autonomous assessment and diagnostic skills.
* - Excellent communication and multidisciplinary co-ordination abilities.
* - Skilled in using SystmOne clinical system.
* - Prior experience in Discharge to Assess or primary care setting.
* - Qualification or extensive experience in frailty, geriatric assessment, chronic disease management in a primary care setting.
* - Familiarity with CHC assessments and safeguarding procedures.
* - Leadership experience in a primary or secondary care setting.
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.
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