PCN Care Home & Housebound Patient Coordinator

Job description

Job responsibilities

Below are the core responsibilities of the Care Coordinator role. This list is not exhaustive and will be reviewed on an annual basis or sooner if deemed necessary. There may be times when the post-holder is required to carry out tasks outside of the list below to assist with the needs of the Practice/ PCN:

Patient Care

• Arrange and conduct regular patient home visits and Care Home ward rounds, the regulatory of this will vary for each Care Home, patient, and their allocated Practice (this should be reviewed and documented on an annual basis). The Care Coordinator will use these visits to collect and update relevant patient information such as new hospital attendances, falls, medication reviews/ issues, if service or other referrals were discussed and/ or made, and updates regarding patients who are approaching the end of their life.
• During or upon returning to their workspace the Care Coordinator will securely transfer the above patient information over to the Practices clinical system
• Work closely with patients, their families, Care Home staff, caregivers, and patient advocates to develop a comprehensive personalized care and support plans. These holistic plans will identify and address all of the patients care needs while centering what matters most to them. The plans will align with best practices to ensure high quality, patient focused care. Through direct collaboration with the patient and their circle of support, the Coordinator will create tailored plans that reflect the patients values, priorities and goals
• Provide coordination and navigation for patients, their families and their carers across health and care services, Social Prescribing Link Workers, Health and Wellbeing Coaches and other relevant primary care professionals
• Guide patients and their families in considering and documenting future care preferences and treatment wishes for times when they cannot make decisions themselves
• Help patients manage their needs by answering questions, scheduling and managing appointments, while providing high-quality verbal or written information to support their care decisions
• Connect patients, their families and carers with access to interventions, support and resources that improve their health and well-being, and build their knowledge, skills, and confidence
• Ensure that patients with a dementia diagnosis receive timely annual reviews. Any change or decline in their condition should be closely monitored and if necessary, passed on to a clinician for further assessment
• Ensure that patients on the learning disability register receive timely annual reviews and care catered to their needs
• Identify newly registered housebound patients and arrange appropriate support and instructions following the initial introduction
• Ensure that all new patients receive relevant assessments and checks, in accordance with new patient protocol
• Assist patients to manage and expedite referrals
• Offer support for cares and carryout carers reviews on behalf the allocated Practice

Multidisciplinary Working

• Attend Multidisciplinary meetings
• Identify local statutory, voluntary and community support services that could assist individuals in achieving optimum health and wellbeing. Develop positive relationships to coordinate responsive, effective care packages for patients
• Assist in coordinating the annual Flu and COVID vaccines programs by obtaining consent from patients, run searches to aid in planning clinics, liaising with Care Home manager, Housebound patients and their carers alongside the Practices Clinical Lead
• Coordinate annual reviews and Structured Medication Reviews (SMRs) with Lead Clinicians, Carers, MOCH Pharmacist and/or Care Home matron
• Share good practices and outcomes with the PCN and Care Homes
• Meet regularly with the Care Coordinator team for peer support, shared learning and service development
• Schedule time with Clinical Leads for Clinical Supervision, professional and personal development
• Attend PAC meetings
• Attend Practice meetings when required
• Occasionally attend PCN Board meetings to provide updates on Enhanced Health in Care homes (EHiCH) alongside other projects

Quality & Safety Management

• Alert other team members to concerns about risk, quality, and safety
• Identify, report and take action on any safeguarding issues or quality of care concerns arising from working with patients and refer issues onwards as appropriate
• Ensure all patient care plans remain up to date, well evaluated and revised as necessary, including after hospital admissions and discharges, significant health changes, falls, or patient/ caregiver concerns
• Document end of life according to end of life protocols
• Document any falls according to falls protocol
• Participate in clinical governance activities and contribute to improving health outcomes through audits, risk management and quality improvement initiatives
• Use healthcare technologies to collect data for audits and utilise clinical audit to monitor service quality, service delivery, patient access and continuity of care
• Help develop efficient systems, processes and protocols
• Follow professional and organisational policies
• Effectively manage time, workload, and resources
• Assist in organising and participating Care Homes educational meetings (i.e. send invites, take minutes etc.)
• Contribute to team effectiveness and performance through personal reflection and make suggestions where required
• Meet all reporting requirements and deadlines per NHS Quality and Outcome Frameworks

Person Specification

Qualifications

Essential

• GCSE Grade 4 (or equivalent) in mathematics and English
• Completed or willing to complete the PCI accredited care coordination training course prior to taking referrals

Desirable

• Health & Social Care Qualification
• Qualification and/or training around care planning and coordination
• Qualification and/ or training around residential care
• Qualification and/or training around learning difficulties/ autism

Personal Qualities

Essential

• Positive and confident persona
• Approachable and supportive towards colleagues and patients (able to empathize in difficult/ distressing situations)
• Able to use initiative and problem solve
• Resilient and able to operate in a calm professional manner during busy and high demand periods
• Flexible and cooperative dependent on the needs of the PCN/ Practice
• Highly motivated and focused
• Willing to learn and develop
• Ability to maintain effective working relationships and to promote collaborative practice with colleagues
• Committed to reducing health inequalities and proactively working to reach people from diverse communities

Experience

Essential

• Experience working in a care role, within health and social care, learning support or public health/health improvement
• Experience working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience working with people who have complex health and care needs to improve their health and wellbeing
• Experience collecting, monitoring and evaluating data, using the figures to measure the impact and quality of services
• Working with people with dementia, Alzheimers or other conditions that affect their ability to communicate, and their carers and advocates
• Experience of working in a multi-disciplinary team
• Experience of Mental Capacity Issues

Desirable

• Experience working within a personalised care role within the NHS and/ or social care
• Experience working with elderly / vulnerable people, encouraging them to become more confident and coping skills
• Experience and/or training in personalised care and support planning
• Experience of working within General Practice
• Experience using SystmOne or EMIS

Knowledge

Essential

• Strong understanding of person centred care and care service approaches
• Knowledge of Local primary care health services and support, both statutory and third sector
• Obtain strong knowledge and understanding Safeguarding, Confidentiality and GDPR
• Sound knowledge of local primary care health services and support, both statutory and third sector
• Understanding of equal opportunities, diversity and inclusion
• Knowledge of how the NHS works, including General Practice and Primary Care Networks
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers

Desirable

• Awareness of issues relating to Advance Care Planning and the ReSPECT process

Other requirements

Essential

• Meet the Disclosure Barring Service (DBS) check requirements
• Willingness to work flexible Hours, when required, to meet demands
• Able to drive to different PCN sites and homes

Skills

Essential

• Exceptional communication skills, both written and oral with patients, their families, carers, partner agencies and colleagues
• Strong listening ability, able to identify the patients needs while handling sensitive situations in a respectful way
• Able to easily build rapports with patients and their family/ carers to encourage trust and confidence in the service provided as well as themselves
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Competent IT literacy as well as MS Office and email
• Excellent organisation skills
• Able to efficiently plan and prioritise tasks and workflow
• Self-autonomous but able to work within both Practice and Pharmacy teams

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Maywood Surgery

Address

225 Hawthorn Road

Bognor Regis

West Sussex

PO21 2UW

Employer's website

https://www.maywoodsurgery.com/index.aspx (Opens in a new tab)