Frailty Case Manager

at  Oxleas NHS Foundation Trust

An exciting opportunity has arisen for a Registered Nurse, Allied Health Professional or Qualified Social Worker to join the Greenwich Frailty Team. Our key aim is to ensure patients remain at home with appropriate health and social services support, reducing avoidable non elective admissions. This is achieved by providing a planned multidisciplinary assessment service designed to support GP’s and other primary and community care practitioners to keep people independent at home or in the community for longer, maintaining their quality of life by providing additional management of sub-acute exacerbations of existing long term conditions and or functional decline in people living with frailty.
Identifying people with frailty and improving their care and support are priorities for health and care systems. The NHS Long Term Plan and Five Year Forward View include aims for the NHS and social care relating to frailty care. Our goal is to develop an approach to care co-ordination to support moderately frail people in Greenwich to remain as independent as possible and prevent unnecessary deterioration. We plan to bridge the gap between primary, secondary and social care to ensure frailty is recognised early in all care settings and that people living with frailty have:
Access to services that promote healthy ageing,
Care planned, with them, in advance, so they stay as well as they can
An agreement with us about what to do when their condition deteriorates
The post holder will carry out a Comprehensive Geriatric Assessment (CGA) with patients in their own homes to develop an integrated care plan which will be reviewed at Multi-disciplinary meetings with all stakeholders which includes Consultant Geriatricians and Psychiatrists, GPs, Psychologists and Pharmacists. Once integrated care plans have been devised the post holder will work with the Frailty Team Care Navigators to ensure co-ordination of the care plan and case manage patients on caseload.
Oxleas Values
Oxleas offers a wide range of NHS healthcare services to people in community and secure environment settings. Our services include community health care such as district nursing and speech and language therapy, care for people with learning disabilities and mental health care such as psychiatry, nursing and therapies. Our multidisciplinary teams look after people of all ages and we work in close partnership with other parts of the NHS, local councils and the voluntary sector and through our new provider collaboratives. Our 4,300 members of staff work in many different settings including hospitals, clinics, prisons, secure hospitals, children’s centres, schools and people’s homes.
We have over 125 sites in a variety of locations in the South of England. In London we operate within the Boroughs of Bexley, Bromley Greenwich and into Kent. We manage hospital sites including Queen Mary’s Hospital, Sidcup and Memorial Hospital, Woolwich, as well as the Bracton Centre, our medium secure unit for people with mental health needs. We are the largest NHS provider of prison health services providing healthcare to prisons within Devon, Dorset, Bristol, Wiltshire and Gloucestershire, Kent and South London. We are proud of the care we provide and our people.
Our purpose is to improve lives by providing the best possible care to our patients and their families. This is strengthened by our new values:
We’re Kind
We’re Fair
We Listen
We Care
The post holder must have relevant clinical experience, an interest in staff development and making a difference to the care of patients presenting with frailty. You will need to be a versatile, adaptable team player who has good organisational skills. You will be required to use multiple computer systems therefore a good knowledge of IT is essential.
The Case Manager role brings together health and social care expertise to deliver holistic integrated care for elderly patients in Greenwich. This approach to providing care to frail people includes the following key functions:
Risk Stratification and managing risk.
Holistic assessment of health, social and wellbeing needs
Personalised Care Planning
Care delivery and care coordination.
Prevention and Self care
Patient centred multidisciplinary team working.
The post holder will work collaboratively with partners in care delivery to improve outcomes and experiences for frail patients and their carers
The role will involve both care coordination and care delivery and aims (where appropriate) to prevent duplication and minimise the number of professionals involved in the care of the patient

Please refer the Job description for details