Consultant Lead for CPMG Team - London, United Kingdom - Kilburn Primary Care Co-Op Ltd

Description

Job summary

Geriatrician/ General Physician required for our wellestablished friendly MDT meeting. If you enjoy working with a range ofdisciplines and coordinating services for complex patients then this is therole for you

We are looking for 8 hours a week, 50:50 on Admin and attending MDT Meetings.

Main duties of the job

The post holder will provide consultant input and clinicaloversight to the Complex Patient Management Group (CPMG) for whole systemintegrated care in Kilburn. Together with the CPMG team the post holder will managecomplex frailty patients, in partnership with their families and carers toensure they have a tailored personalised care plan, have access to localresources in the community through social prescribingto preventunplanned hospital admission.

About us

An exciting opportunity has arisen to join our CPMG team here atKilburn Primary Care Network. As a Geriatrician/General physician, you willplay a pivotal role in providing comprehensive medical care and support for theneeds of our most Complex Patients Your expertise in geriatric and general medicinewill contribute to enhancing the quality of life and well-being of our patientswith complex medical issues.

Job responsibilities

Objectives for the Complex Patient Management Group

Support GPs in the management of their mostcomplex patients and provide advice, support, and education on how to do thisin the community.

Advise on mitigation strategies in bothmedical and social care provision to prevent unplanned hospital admissions andpromote wellness.

Advise on services to promote health and well-beingvia the health, social care and voluntary sectors for patients, families, and carers.

Complex Patient Management Group Services

Multidisciplinary review of patients referredto the service by a team composed of GP, Consultant Geriatrician, Nurse CaseManager and Care Navigator liaising with Social and Mental Health Services withtriage for level of service and advice.

Provide Nurse Case Assessment and Managementof Patient Needs.

Provide Advice on the Medical and Social Caremanagement for referred patients.

Direct Advice & Support to a GP forspecific issue

Review of care plans of difficult to manage patients.

Virtual Ward Round of patients on case load.

Face to Face Review of exceptionally complex patientsmedical needs (to be performed after virtual MDT review of the patient anddecided by the team)

Provide Care Navigation for Social Servicesfor patients.

CPMG is a Consulting Service for Support of Kilburn GPs not aCare Service

For the support and education of Kilburn GPsand Nurses to manage more complex patients with appropriate support from thePHC Team & Secondary care first and members of the CPMG second.

A consulting service with limited resourcesmost patients will be assessed, a plan made, and care advice returned to the GPto action with specific support from the team as outlined in the plan.

Use of existing medical and social services tobe advised not replaced by this service.

Face to face review of patients only forcomplex patients will be decided by the MDT.

Expected outcomes of CPMG

GPs to be provided with cohesive care plansfor them to action concerning medical care with support from the Case Managerand Care Navigator as needed.

Clinical Responsibility to be retained by theGP, medical advice, and support to be given to the GP and ongoing review to beprovided by the GP with open door for advice if the situation changes.

Once stable Case Manager will discharge backto GP with open door to provide advice or re-referral if change occurs.

Care navigator to provide and support links toservices and discharge from case load once they have been actioned.

Experience

Essential

Qualifications

Essential

Desirable

SKILLS

Essential

PERSONALITY

Essential