Detailed job description and main responsibilities

Clinical Responsibilities

Review patients screened as frail in the Emergency Department, Ambulatory care and the Acute Admissions wards, according to our Frailty Pathway criteria. In conjunction with the Consultant Geriatrician/ Frailty MDT provide expert assessment of frail elderly patients on admission to determine the most appropriate pathway of care to meet the patient’s needs and direct patients accordingly.

 Liaise closely with other members of the multidisciplinary team including community colleagues and within the hospital.

 Ensure good communication between members of the multidisciplinary team to ensure safe and timely hospital discharge of identified patients as well as appropriate admission to hospital.

 Act as patient and carer advocate.

 Communicate with patients, carers and relatives - involve them in care planning and resolve concerns.

 Provide patients and carers with individual details about their condition and management.

 Demonstrate ability to communicate complex and sensitive information through good communication skills even when there are significant barriers to communication.

 Communicate information to patients and carers in an understandable way.

 Assess the patients’ need for additional services and refer as necessary. 

Gain valid informed consent to intervention and treatment. 

Provide spontaneous and planned advice, teaching and instruction to patients, carers, relatives and other health professionals to promote long term condition management and ensure a consistent approach to patient care. 

Manage potentially stressful, upsetting and emotional situations in an empathetic manner, including delivering bad news, providing palliative care support and discussions about future management and resuscitation. 

Be able to manage own work load

Arrange/attend team/family meetings in conjunction with other relevant members of the multidisciplinary team. 

Act as a resource for medical doctors, nurses and allied health professionals across Whittington Health on the care of older people. 

Act as part of the multidisciplinary team and ensure patients who are discharged receive a high standard of specialist care. 

Initiate and implement changes in clinical practice which improve standards of care and health outcomes for patients. 

Work within agreed medical, nursing and trust protocols as well as Develop standards of practice against which quality of care can be measured. 

Identify clinical issues and incidents that reduce quality of patient care and develop strategies to counter these to ensure safe and effective care. 

Identify and resolve patient related or service problems and prioritise conflicting needs.

Education 

Identify education needs in relation to care of older people. Develop a training strategy to increase understanding amongst staff of the needs of older people. Facilitate the development of knowledge and skills in staff, recognising and developing aspiring leaders within older people, frail elderly and dementia care services. 

Critically appraise evidence-based literature and use this knowledge to lead on education programmes within the hospital and the community. 

Employ a range of methods in education and training appropriate to the topic, participants, facilities available and event.

Prepare and provide learning materials. 

Encourage and support research-based practice linking this to relevant service development. 

Devise and provide written information for patients and carers to enhance their understanding. 

Be responsible for identifying own training and development needs. 

Participate in appraisal using reflective practice. 

Continue own professional development through the pursuit of relevant professional and academic study. 

Leadership, Management and Service improvement 

Champion and lead the organisation’s commitment to provide a service for frail older people that is patient centred, flexible, comprehensive and clearly focussed on timely diagnosis, appropriate interventions and multidisciplinary discharge planning. 

Contribute to the development of a strategic plan for the frailty service and other service development strategies with specific reference to the nursing contribution to service improvement objectives.

Provide a visible, accessible presence throughout the Trust, demonstrating clinical leadership and acting as a credible role model. Act as a resource for advice, guidance, support and decision making. 

Provide leadership and support to enable a multidisciplinary approach to delivering improvements in patient safety for older people.

 Motivate and empower staff to perform their role to ensure a confident, competent, questioning and enthusiastic workforce. Inspire others by action and example, challenging traditional practices and encouraging innovative problem solving by staff.

Promote a culture where change is embraced and there is constant challenge to existing services in order to achieve and sustain improving standards of care and practice in relation to older people. 

Monitor trends in incidents and promote service improvements that are responsive to patient feedback.

Ensure that clinical practice has patients, their families and carers at its centre, is evidence-based and supports patients to make informed decisions regarding their pathway of care. Engage with patients, families and carers in order to establish their views on services, promoting patient and public involvement in the evaluation and improvement of services.  

Initiate projects that increase the profile of the COOP service and team members.  

Represent the Trust on committees relevant to the care of older people nationally and locally. 

Flexibly plan and organise own time to meet the demand of the service. 

Be involved in the development of relevant care guidelines. 

Have line management responsibilities

Research and Audit 

Ensure audit programmes are consistent with the service objectives. 

Undertake audit/QIPS as required to support service development.

Be proactive in ongoing audit in order to assess the effectiveness of the service.

Participate in and critically evaluate research finding and to disseminate them appropriately.