Role Profile

The Occupational Therapist will deliver home-based assessment and intervention for patients living with frailty, focusing on functional independence, activities of daily living (ADLs), and environmental risk management.

The role centres on improving a patient’s ability to safely manage at home, through targeted intervention addressing functional decline, cognitive challenges, and environmental barriers.

Working as part of the Primary Care Network (PCN) multidisciplinary team (MDT), the Occupational Therapist will support proactive frailty management, contributing to shared care planning and coordinated, person-centred care across primary, community, and social care services.

This role plays a key part in reducing avoidable demand across primary and secondary care through early intervention, functional rehabilitation, and prevention of crisis related to loss of independence.

This role involves regular home visiting across the PCN footprint and therefore requires travel between patient locations.

Outcomes Expected

You will support the PCN with overriding objectives to:

• Prevent avoidable hospital admissions
• Improve functional independence and ability to manage at home
• Reduce falls risk through environmental and behavioural intervention
• Support safe discharge and recovery at home
• Reduce GP workload through specialist functional assessment

Key Responsibilities

Provide specialist occupational therapy assessment and intervention for patients within primary care, including:

• Functional assessments focusing on activities of daily living (washing, dressing, meal  preparation, mobility within the home)
• Frailty assessments and proactive case management of high-risk patients
• Falls risk assessment and prevention strategies, including environmental modification
• Assessment of the home environment to identify risks and support safe independence
• Provision of equipment, adaptations, and practical strategies to support daily living
• Supporting patients and carers with behavioural strategies and routines to maintain independence
• Cognitive and functional assessment where appropriate (e.g. impact on safety and daily function)
• Individualised intervention plans to improve safety, independence, and confidence at home
• Supporting safe discharge from hospital and reducing readmission risk

You will work with patients to develop person-centred goals and care plans that focus on improving independence, safety, and quality of life.

Person Specification

Essential

• Degree or MSc in Occupational Therapy
• HCPC registered
• RCOT membership
• Experience working with older adults or people living with frailty, including:
  – Functional decline and loss of independence
  – Activities of daily living (ADL) impairment
  – Falls risk and home safety
  – Cognitive or behavioural factors impacting independence
• Post-hospital discharge support:
  – Experience of functional assessment and rehabilitation
  – Strong communication and MDT working skills
  – Ability to work autonomously within a community setting
  
  Full clean driving licence and access to own vehicle

Desirable

• Experience working in primary care or community services
• Experience working with care homes or frailty pathways
• Knowledge of NHS primary care systems and MDT working
• Postgraduate training in frailty, rehabilitation or advanced practice