Main Responsibilities Work with GP Surgeries to identify potential referrals to the Tier 2 Frailty Service Working with Frailty Team colleagues, use risk stratification tools to identify patients at risk and ensure they receive assessment and care in a timely fashion Support the Frailty Team in the delivery of Complex Care, coordinating care delivery between service providers as needed Make Social Prescribing referrals, as appropriate Contribute to planned team huddles and multi-disciplinary team meetings Hold regular welfare calls with the patient / carer Maintain excellent working relationships with all those involved in the provision and development of services for those with long-term conditions, sharing regular updates of planned care and any changes when they occur Work closely with the Frailty Team and others involved in care delivery to ensure patients have relevant referrals and access in place; attend and liaise with the Frailty Team MDT groups, regularly attending case conferences and providing relevant updates Communication Skills The post-holder will recognize the importance of effective communication within the team and will strive to: Communicate with patients in a welcoming way, which is non-judgmental and respects patients feelings, circumstances, and rights Utilise and demonstrate sensitive communication styles to ensure patients are fully informed of reasons for contact when contacting them for example, on welfare calls Communicate highly sensitive patient information and progress effectively with other team members and outside relevant health and social care providers, as appropriate Ensure all documented notes are contemporaneous Supporting Responsibilities Quality Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance Participate in the management, review, and identification of learning from patient complaints and significant events Deliver evidence-based care according to the National Institute for Clinical Excellence (NICE) and Care Quality Commission (CQC) guidelines Information Technology Possess basic computing and keyboard skills Have a good working knowledge of relevant areas of clinical systems and other programmes as appropriate to the role Demonstrate a good working knowledge of the policy on information and clinical governance Research and Audit Contribute to the collection of data for research/audit purposes Identify audit topics relevant to the Frailty Team Professional and Educational Responsibilities Ensure all Statutory and Mandatory training is complete Avail of all opportunities to develop both clinical knowledge and practical skills

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