PCN Frailty Team Care Coordinator

Job description

Job responsibilities

Key Responsibilities

Case Identification:

- Support the Frailty Nurse as required to undertake digital risk stratification

- Transpose data onto our clinical systems, ready to enable care coordination

Holistic Assessment:

- Support the Frailty Nurse to triage potential patients to determine who receives an assessment

- Support the Frailty Nurse to determine what action to take with those patients who do not receive an assessment, including ensuring actions are undertaken

- Contribute to the completion of the assessments as determined by the Frailty Nurse, inputting the information gained into a digital template

Personalised Care and Support Planning:

As determined by the Frailty Nurse:

- Ensure each patient who has an assessment has a Personalised Care and Support Plan that has been discussed and finalised with the patient and any carer/family; this will help to manage their needs and achieve better health and wellbeing outcomes

- Ensure a ReSPECT plan is completed for each patient who has an assessment

Coordinated and Multi-Professional Working:

- Be responsible for coordinating the care of each patient, ensuring close multi-agency and multi-professional working, especially with the local Integrated Neighbourhood Team(s), to facilitate delivery of each patients personalised care and support plan

- Use and be fully responsible for the care coordination function of our clinical systems as the method of managing and coordinating the care for each patient

- Be responsible for ensuring relevant colleagues complete their agreed interventions listed in the personalised care and support plan, escalating issues if required to the Frailty Nurse

Continuity of Care including Review:

- Be responsible for ensuring each patient who has an assessment has their plans regularly reviewed (e.g. every six months) according to need

- Be responsible for ensuring each patient who has a significant life event is offered a review e.g. when they have been admitted to hospital on a planned or unplanned basis, or had a fall, or a close family bereavement

General:

- Alongside the Frailty Nurse, provide leadership and support to the Frailty Team Administrator as required.

- Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice

- Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.

- Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing.

- Provide co-ordination and navigation across services, helping to ensure people and their carers receive a joined-up service and the appropriate support from the right person at the right time.

- Work collaboratively with GPs and other General Practice team members within the PCN to proactively identify and manage a caseload, and where appropriate, refer back to other health practitioners within the PCN.

- Support the co-ordination and delivery of multidisciplinary teams with the PCN, when required.

- Identify people, using clinical tools, who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations

- Explore and assist people to access a personal health budget where appropriate and available.

- Undertake clinical coding to create reliable patient records used for diagnosing accurately, planning treatment, and ensuring patient safety.

- Competently use clinical systems and templates to capture, and report patient records.

- Follow-up on communications from out of hospital and in-patient services.

- Through our clinical systems and tools, maintain records of referrals and interventions to enable monitoring and evaluation of the service.

- Contribute to risk and impact assessments, monitoring and evaluation of the service.

- Work with commissioners, Integrated Neighbourhood Team members and other agencies to support and further develop the Team Care Coordinator role and the work of the wider PCN Frailty Team.

Person Specification

Experience

Essential

• - Experience of working within multi-professional team environments
• - Experience of data collection and using tools to measure the impact of services
• - Experience or training in personalised care and support planning

Desirable

• - Experience of working directly in a care coordinator role
• - Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Knowledge and Skills

Essential

• - Full UK Driving Licence and access to a vehicle
• - Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, families, carers
• - Understanding of, and commitment to, equality, diversity and inclusion
• - Strong organisational skills, including planning, prioritising, time management and record keeping
• - IT literate and proficient in MS Office (including Excel), able to comply with required record keeping on clinical systems
• - Person Centred - Prioritises the individuals needs, preferences and dignity
• - Knowledge of Safeguarding Vulnerable Adults policies and processes

Desirable

• - Knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social

Qualifications

Essential

• - GCSE English and Mathematics (or equivalent level) Qualifications and training
• - Willing to undertake appropriate training to best support the Frailty nurse and needs of the Frailty Team when applicable

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

Cheltenham Peripheral Network

Address

c/o Leckhampton Surgery

17 Mooreend Park Road

Cheltenham

Gloucestershire

GL53 0LA

Employer's website

https://www.leckhamptonsurgery.co.uk/ (Opens in a new tab)