General Practitioner - Hospital @ Home

We wish to appeal to GPs with a desire to be involved in developing home-delivered, patient-centred care who themselves strive to make a difference and be influential in shaping services for the future. The lead decision maker post holder will work in partnership with our Lead GP and multi-disciplinary team (MDT) to grow the ‘Hospital@Home’ service – a frailty virtual ward serving frail people in Middlesbrough, Redcar and Cleveland and working in partnership with North Tees for patients in Stockton and Hartlepool and the wider health and social care system. Hospital@Home is a patient-centred care model with shared decision-making. There is an ongoing programme to offer more clinical pathways, enabling more patients to be cared for at home.

Core Functions

• Provide clinical, educational and strategic support to the team, including clinical skills development and knowledge tutorials.
• Work in partnership with the Consultants and GP in Older Person’s Medicine to establish an integrated frailty management system.
• Collaborate with the leadership teams for Community Nursing and Therapies to support the development of the reactive team responding to frailty crises in the community, preventing unnecessary hospital admission.
• Collaborate with integrated neighbourhood teams, primary care networks and the leadership teams for Community Nursing and Therapies to support the development of the proactive team preventing frailty crises in the community.
• Facilitate and support early discharge for inpatients where possible.
• Involvement in the development of proactive care service.
• Provide senior clinical decision-making to the team.
• Develop networks with key stakeholders.
• Provide pastoral support, mentorship and educational training in the management of frailty to staff within the healthcare economy.
• Daily ward round/board round.
• Maintain continuity of care for patients and colleagues – same doctor each day for a run of preferably three days with handover of complex cases to out-of-hours staff and to the doctor taking over a run of shifts.
• Discussion of cases with clinical staff who visit patients.
• Patient visits.

Our ambition is to become the place of choice for acutely ill frail patients, with increasing access to diagnostics and home interventions, working in a collaborative, integrated, fluid approach to providing healthcare in the community rather than static bedded care. In addition to this we are developing a strategy for proactive care; these post holders will be key to its development, focusing on delivering proactive care to the most complex and vulnerable patients with the aim of reducing avoidable exacerbations of ill-health and improving the quality of care for older people. These senior clinicians will work within an MDT with the aim of providing safe, excellent care for patients in their own home, providing continuity of care for patients and continuous improvement in quality and service development.