PCN/INT Frailty Nurse

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Main Responsibilities These responsibilities are for an identified cohort of patients. Clinical Care Proactively identify patients with moderate to severe frailty using recognised frailty indices and practice registers Undertake comprehensive geriatric assessments (CGA), including functional, cognitive, social, and medication review Develop, document, and regularly review personalised care and support plans in partnership with patients, families and carers Identify patients at risk of unplanned hospital admission and initiate proactive interventions to reduce that risk Support patients and families with advance care planning discussions, including ReSPECT forms and end-of-life wishes, escalating to GPs or specialist palliative services as appropriate Recognise and respond appropriately to signs of clinical deterioration, escalating to GPs or emergency services where necessary Care Home Ward Rounds Deliver structured weekly ward rounds at designated care homes Review resident health status, medication, and care plans in collaboration with care home staff Liaise with GPs to action clinical decisions arising from ward rounds Build strong working relationships with care home managers and staff to support early identification of resident health concerns Multidisciplinary Working Present complex and high-risk frailty patients at the monthly INT MDT meeting, providing clinical summaries and care plan updates Coordinate input and follow-up actions from MDT discussions across relevant services Work collaboratively with PCN Pharmacists, Social Prescribers, Care Coordinators and community teams to deliver joined-up, patient-centred care Act as a point of clinical liaison between general practice and community/social care services for frailty patients Administration and Governance Maintain accurate, timely clinical records in line with practice and PCN information governance policies Contribute to PCN frailty data collection, audit, and outcome reporting Participate in relevant clinical audits and quality improvement initiatives Attend PCN and practice meetings as required Professional Development Maintain NMC registration and up-to-date clinical competencies Participate in regular clinical supervision, appraisal, and revalidation processes Undertake training relevant to frailty, gerontology, and long-term condition management Keep up to date with national and local guidance relevant to frailty care (e.g. NICE, BGS, local ICB pathways)