Frailty Therapist

NHS; Weymouth; On-site; GBP 30,000 - 45,000

Job description

We are looking for an enthusiastic individual to join our well-established Weymouth and Portland Frailty Service and welcome applications from either Physiotherapists or Occupational Therapists. The rate of pay reflects the opportunity for this to be a development post.

We are one of the first sites in Dorset to have started work on developing our Integrated Neighbourhood Team (INT) and the Frailty Service is an integral part of that.

This role involves home visits to patients who are frail and often complex. These patients will generally be living in their own homes across Weymouth and Portland; some will be seen in a clinic setting where the therapist will contribute to a comprehensive geriatric assessment, while others may need a detailed holistic assessment with a therapy focus.

This role involves working with patients who could be registered at any of the GP Surgeries in Weymouth and Portland. Clinical support will be provided by the Frailty Team GPs and Therapists already working in the team.

There are already close links with ICRT and as the INT develops, there will be more opportunities to work even closer. A robust and comprehensive induction will be provided.

Main duties of the job

The Weymouth & Portland practices have a well-established Frailty team which has been expanding since April 2015 to provide proactive holistic care for complex frail patients who are living in care homes or housebound. The team has also established an Ageing Well Clinic in 2022. This team is led by a General Practitioner and includes Frailty Practitioners who are Nurses, Advanced Clinical Practitioners, paramedics, Occupational Therapists, and are supported by a Frailty Care Coordinator & Health Care Assistants. There is a focus on ongoing case finding using risk profiling measures & population health management.

The main aims of the service are to:

• Deliver EHCH (enhanced health in care homes)
• Provide proactive, routine assessments based on a Comprehensive Geriatric Assessment to patients living in their own homes
• Make timely referrals to the wider multi-professional team to improve overall wellbeing, reduce risk of falls, reduce risk of deterioration, and reduce risk of hospital admission.
• Complete Personalised Care and Support Plans, focusing on what matters most to the patient
• Proactively identify patients who would benefit from a holistic assessment
• Support Ageing Well in the community, focusing on reducing the progression of frailty/reversing it where possible
• Assess patients who have been re-referred with frailty-related decline
• Ensure effective teamwork to ensure the right patient is seen by the right staff member at the right time

About us

Two Harbours Healthcare is a not-for-profit organisation led by local General Practices in Weymouth and Portland. Our goal is to work more closely together (and with stakeholders) to share expertise, resources, and provide services for the NHS.

Job responsibilities

Housebound Patients:

• Be an integral member of the WECS team comprising GP(s), Nurse Practitioner, Nurse, HCA, OT, paramedic, ACPs, Physiotherapist, and Frailty healthcare assistants
• Conduct home visits to identified patients to complete therapy assessments, which may include baseline assessments using an agreed proforma CGA template to include (but not exclusively) continence, skin, nutritional status, care needs, and unmet needs. Lone working policy to be followed.
• Develop specialist care and/or rehabilitation programmes to promote and sustain independence/wellbeing for the individual or carer in the relevant setting, which will usually be a residential setting.
• Contribute towards the development of Therapy within The Frailty Team. Monitor standards of practice.
• Refer patients when appropriate to Frailty Health Care Assistants to collect additional information or complete additional assessments e.g. weight monitoring, BP checks, ECG, phlebotomy etc.
• Conduct follow-up visits to patients following a new assessment or after a re-referral until identified problems are addressed
• Make referrals to the wider MDT (including third sector) if and when appropriate
• Develop and communicate therapy management plans working in the integrated neighbourhood team
• Ensure patients who are discharged from the service are aware they can re-refer if deteriorating, and how they can re-refer
• Manage own caseload of patients, determining appropriate frequency for review and scheduling appointments
• Support with comprehensive data collection
• Contribute to a Personalised Care and Support Plan using the Dorset Care Plan
• Be aware of and understand the supporting document Housebound visiting model specification

Ageing Well Clinic:

• Deliver the requested components of an assessment in an outpatient/community setting
• This assessment will form part of a CGA
• Patient goals are an essential component of the review, using the principles of personalised care and support planning
• Be aware of and understand the supporting document Ageing Well Clinic Specification
• Focus on falls, mobility, and transfers, encouraging independence and activity

For all patients:

• Contribute towards the Dorset Care Plan (The Personalised Care and Support Plan of choice in Weymouth and Portland)
• Utilise clinical skills e.g. venepuncture, manual BP, weight when appropriate
• Develop towards - Advance Care Planning discussion to include discussion about resuscitation status (training and experience dependent)

Other:

• Attend surgery MDT meetings or EHCH MDT meetings if requested to do so
• Ensure work emails are regularly accessed
• Ensure work mobile is carried at all times and that messages are picked up at regular intervals throughout the working day
• Interpret data from various sources e.g. frailty data, MDT data, frailty registers to determine which patients would benefit from holistic review if requested to do so
• Manage workload effectively and ensure that sufficiently detailed contemporaneous notes are kept at all times.

Person Specification

Knowledge and skills

• Excellent communication skills with patients with complex needs and their families/carers
• Clinical observation skills
• Therapy skills, including rehabilitation, goal setting, and equipment provision
• End of life care
• Mental and physical health experience
• Ability to prioritise workload
• Knowledge of SystmOne
• Confidence in lone visiting to complex patients
• Therapy competencies
• Venepuncture (training can be provided)

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.

Contract

Permanent

Working pattern

Full-time, Part-time, Job share, Flexible working