Frailty Practitioner - Northern Parishes PCN

The Frailty Practitioner will conduct comprehensive assessments of frail patients, identifying their physical, psychological, and social needs. They will develop personalised care plans in collaboration with GPs and other healthcare professionals, ensuring a holistic approach to patient care. By coordinating care across multiple disciplines, the frailty practitioner will help to streamline services, reduce duplication, and ensure that patients receive timely and appropriate care. This role will also involve providing education and support to patients and caregivers, helping them to manage conditions at home and reduce the need for acute care services. Identification and Assessment The Frailty Practitioner will assist in identifying patients who are living with frailty using tools such as the electronic frailty index (eFI). They can conduct comprehensive assessments to determine the level of frailty and identify specific needs. Care Planning They will help develop personalised care plans
tailored to the individual needs of frail patients. This includes coordinating with other healthcare professionals to ensure a holistic approach to care. Monitoring and Follow-Up The Frailty Practitioner will regularly monitor the health status of frail patients, ensuring that any changes in their condition are promptly addressed. This can help in preventing hospital admissions and managing chronic conditions more effectively. Medication Management They will review and manage medications to reduce the risk of polypharmacy and adverse drug reactions, which are common in frail patients as well as working with our Pharmacists and Pharmacy Technician to identify patients who require an SMR and support with implementing any medication safety measures. Support and Education The Frailty Practitioner will provide education and support to patients and their families about managing frailty, including advice on nutrition, exercise, and fall prevention. Coordination of Services The Frailty
Practitioner will act as a liaison between the GP practice and other services such as social care, community nursing, and specialist services, ensuring that patients receive comprehensive and coordinated care. Reducing GP Workload By taking on some of the responsibilities related to the care of frail patients, the frailty practitioner can help to reduce the workload of GPs, allowing them to focus on other complex cases. Improving Patient Outcomes With their specialised knowledge and skills, the frailty practitioner will contribute to better health outcomes for frail patients, improving their quality of life and reducing the need for emergency care.