PCN Healthy Ageing Co-ordinator

1.Main Responsibilities 1.Support the identification of patients who are indicated to be living with Mild/ Moderate/Severe frailty utilising a recommended toolkit (i.e eFI. Or through RWT Care of the Elderly team) 2.Undertake a Healthy Ageing check using an agreed assessment tool, such as Edmonton to determine the level of frailty the patient could be living with which will inform an appropriate intervention 3.Completing any necessary paperwork and referrals within associated Practices within the PCN 4.Collaborative working between multi-agencies across the City including (but not limited to) RWT Care of the Elderly Team, Community Nursing, Social Care, Social Prescribers, Primary Care MDT Coordinators, and other community/ voluntary sector services. 5.Undertake BP monitoring 6.Undertake Urinalysis 7.Proactively case manage patients who are aged 65 and living with mild/ moderate/severe frailty, and could be socially isolated, adopting a holistic approach to review health, social and physical aspects of current daily activities, for example nutrition, hydrations, eye and oral health, physical activities. 8.To identify carers and offer appropriate support, signposting to Carers Support for assessment, voluntary services such as Age UK, handyman services, housing assistance, lunch/ social/ physical activity groups.



9.Provide lifestyle advice to patients making any necessary referrals within associated Practices within the PCN 10.Proactively identify patients who are at risk of a fall/ fear of falling, and refer to the community falls prevention team for primary prevention assessment and intervention 11.Undertake weight monitoring at appropriate intervals 12.Ensure specimens are labelled and bagged ready for collection with the necessary paperwork completed 13.Restocking/maintenance of equipment used 14.Restocking of clinical areas and consulting rooms This list is not exhaustive and the post holder may be asked to undertake other relevant tasks within their scope of practice. Before performing these tasks, appropriate, relevant training must be received and documented in the training pack. 2.Professional /Clinical 1.Maintain high standard of personal contact and communication with patients, particularly during treatments 2.Undertake basic observations and collecting specimens as required. 3.To avoid any behaviour which discriminates against your fellow employees, or potential employees on the grounds of their sex, sexual orientation, marital status, race, religion, creed, colour, nationality, ethnic origin or disability 4.To safeguard at all times confidentiality of information relating to patients and staff in adherence with National and local Data protection and Information governance.



5.To behave in a manner that ensures the security of the Practice 6.To adhere to all relevant Practice Policies and Procedures This list is not exhaustive. 3.Administrative/Managerial 1.Participate in the administrative and professional responsibilities of the practice team and on behalf of the PCN 2.Ensure accurate and legible notes of all consultations and treatments are recorded in the patient notes (electronic and patient held) 3.Ensure the clinical computer system is kept up to date with accurate details recorded 4.Ensure accurate completion of all necessary documentation associated with patient health care and registration with the practice 5.Attend and participate in practice meetings as required 6.Assist in formulation of practice philosophy, strategy and policy 7.Restocking and maintenance of clinical areas and consulting rooms 8.To assist in seasonal and special projects as requested e.g. flu campaign 9.Ordering and display of Health Promotion materials This list is not exhaustive. 4.Frailty Competency Framework Tier 1 & 2 The local service specification is strongly aligned to the core capabilities as outlined within the Frailty Core Capabilities (2018) framework.



The framework comprises of a number of capabilities grouped into 4 domains. The framework describes underlying principles, knowledge and skills that may be relevant to an individual role. The focus of this local service will be aligned to Tier 1 & 2 of the competency framework: Tier 1 Those that require general awareness of frailty Tier 2 Health and social care staff and others who regularly work with people living with frailty but who seek support from others for complex management Tier 3 Health, social care and other professionals with a high degree of autonomy, able to provide care in complex situations and who may also lead services for people living with frailty. The post holder will participate in any education and training provided which is aligned with the core capabilities as outlined within the framework 1 & 2.



5. Miscellaneous 1.Establish strong working relationships with GPs and practice teams 2.Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner; 3.Identify opportunities and gaps in the service - and review risks and issues that could impact on service delivery - and provide feedback to continually improve the service and contribute to business planning; 4.Contribute to the development of policies and plans relating to equality, diversity and health inequalities; 5.Work in accordance with the practices and PCNs policies and procedures; 6.Contribute to the wider aims and objectives of the PCN to improve and support primary care.