Job summary
As part of the wider Healthcare of Older People (HOP) team, the post-holder will be based in The Harbour service at Newton Abbot Hospital, providing senior clinical decision-making and clinical leadership to enable people living with frailty to receive timely assessment, treatment and care closer to home. The role incorporates frailty coordination and telephone triage, Harbour @ Home (frailty virtual ward), same day emergency care (SDEC) with direct access to community hospital beds at Newton Abbot Hospital.This post includes contributing to evening and weekend rotas.

Main duties of the job

• Be part of the frailty coordination function, providing clinical telephone triage to referrers including SWASFT, Primary Care, community teams, acute hospital wards, the Emergency Department and Acute Medical Unit (AMU), identifying the most appropriate way to meet the patient's acute needs.
• Hold clinical responsibility and accountability for agreed patients while they are under the care of The Harbour
• Provide senior clinical decision-making and leadership to the multidisciplinary Harbour team and deputise for the GP Lead in their absence.
• Work across acute care, The Harbour and existing community services, particularly Urgent Community Response (UCR), accessing same-day interventions where appropriate.
• Work with intermediate care, Primary Care and the wider community multidisciplinary team.
• Deliver high-quality specialist assessment and intervention for older people living with frailty, using the principles of Comprehensive Geriatric Assessment (CGA).
• Use point-of-care testing, digital monitoring and other appropriate clinical support to facilitate care delivery
• Where appropriate, contribute to the training and supervision of other Harbour clinicians including trainee and qualified advanced clinical practitioners and resident doctors
• Contribute to service development, quality improvement, data evaluation and teaching.

About us
Why Work With Us
The Harbour is Torbay and South Devon's innovative frailty model located at Newton Abbot Hospital, supporting the NHS vision of moving care from acute hospitals into community settings and aligning with our organisational strategy to deliver more integrated, person-centred care closer to home.

It provides a single point of access for older people living with frailty, with patients triaged through adedicated frailty clinical coordination service and directed to the most appropriate support.

Wherever possible, care will be provided at home or within community settings through services such as the Harbour at Home Virtual Ward, Harbour SDEC, Urgent Community Response and intermediate care, ensuring patients receive the right care in the right place, supported byintegrated health, social care and voluntary sector partners.

For patients requiring rapid assessment, diagnostics or specialist review, a Same Day Emergency Care (SDEC) and ambulatory care service will provide an alternative to attending Torbay Hospital.

Where hospital admission is required, inpatient beds will be available at Newton Abbot, with teams working proactively to support timely discharge and recovery closer to home.

Job responsibilities
Communication and working relationships Communicate effectively with patients, relatives and carers, supporting shared decision-makingand a person-centred approach to care and self-management. Provide telephone and virtual clinical advice to SWASFT, Primary Care, community teams and other referrers. Liaise with local GP practices, community matrons, district nurses, pharmacists, allied health professionals, hospital clinicians, IT providers and specialist acute teams. Provide specialist advice and clinical support to practitioners caring for patients in community settings. Ensure clear, accurate and contemporaneous records are made for every patient encounter.

Understand the criteria and considerations for Harbour and acute medicine pathways Triage referrals, determine clinical suitability and accept agreed patients into The Harbour pathways. Apply senior autonomous clinical judgement when managing complexity, uncertainty and clinical risk in community settings. Undertake and contribute to Comprehensive Geriatric Assessment, medication review, deprescribing, anticipatory care planning and treatment escalation planning. Develop proactive management plans to prevent hospital admission and support earlier discharge.

Qualifications
Essential

• Full registration and a Licence to Practice with the GMC
• MRCGP or equivalent
• On the GP Performer's List or on/transferring to TSDFT responsible officer/appraisal pathway
• Up to date with appraisal and revalidation requirements

Desirable

• MD or PhD
• Additional qualification relating to frailty and acute care, e.g. Diploma in Geriatric Medicine, MRCP or MSc
• Membership of the British Geriatrics Society

Knowledge
Essential

• Wide experience managing complex older patients with co morbidities and frailty syndromes, including anticipatory care planning in frailty and dementia care
• Familiarity with frailty identification and management
• Knowledge and understanding of Comprehensive Geriatric Assessment and frailty syndromes
• Experienced in managing and holding clinical risk in community settings

Desirable

• Clinical experience in end of life care/ care home medicine/ Acute medicine

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).