Frailty Case ManagerinWoolwichinWoolwichPUBLISHED MON 21 OCT 2024

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.

About us

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.