Network Care Coordinator - Frailty Care Coordination MDT Pilot

Job description

Job responsibilities

Key responsibilities of the post

a) Identify residents who would benefit from a Proactive Care approach

Coordinate the list of residents who fit the criteria of 65+, moderately frail, with COPD/CVD and are frequent hospital attendees and who could be supported by a Multidisciplinary Team (MDT) approach

Put in place for each resident who fits the criteria a Personalised Care and Support Plan, using EMIS

Cross-reference lists with relevant patient records (and other systems as appropriate) to gain an understanding of the different professionals involved in the care of the resident

Work with the relevant practitioners to prioritise the cohort list

Work closely with practitioners to develop an increased awareness of households and patients who may be vulnerable and in need of support

b) Have discussions with residents focusing on what matters to them

Contact the resident to explain the proactive care offer and invite involvement

Carry out a holistic strengths-based assessment of need, and build trust

Communicate with the frailty and long-term conditions team with regards to health outcomes or any further assessment required

c. Be a core part of Network Team MDTs

To act as a key member of the network MDT leading and supporting the development of effective meetings

Organise and lead monthly locality frailty care coordination MDT meetings

Attend Neighbourhood meeting as part of MDT i.e. frailty, COPD, CVD meetings

Bring for discussion patients identified for the proactive care pathway to the MDT

Work with practitioners to ensure that relevant professionals involved in the care and support of the individual are involved in MDT discussions where appropriate

d. Coordinate support for the resident

Support people in managing their needs

Support people to take up training and employment, and to access appropriate benefits where eligible

Assist people in accessing self-management education courses, or interventions that enable them to support their health and wellbeing

Provide coordination and navigation for people and their carers across health and care services

Signpost residents to frailty, COPD and CVD and other relevant health services

Signpost and work with local authority team to support residents care needs and wider determinants of health (housing, blue badge, employment etc.)

e. Good record keeping

Maintain accurate, confidential and up-to-date documentation on residents, including patients EMIS records

Keep MDT related information up to date (agenda, minutes, follow-up actions)

Ensure safeguarding arrangements are in place to support those residents identified for support

Maintain monitoring and reporting templates up to date

f. Evaluate outcomes for individual residents

Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing using relevant goals-based measures

With the wider Neighbourhood, gather and collate information, evidence and anonymised stories, reporting on outcomes and activity. Ensure effective qualitative and quantitative monitoring and evaluation

g. Leadership

Opportunity to champion the delivery of proactive care within the Neighbourhood, through a successful programme implementation

Opportunity to work closely with practices in coordinating residents if needed

Attend management meetings to update progress and concerns relating to the proactive care programme when required

h. Working with others

Be an active member of the Neighbourhood team to build relationships with General Practice, adult community nursing, adult community therapies, mental health, adult social care and voluntary sector staff. Attend relevant service meetings, forums and contribute to continuous improvement of the Neighbourhood team

i. Supervision and training

Proactively engage in training and support made available and undertake appropriate training with the Personalised Care Institute

Person Specification

Knowledge

Essential

• Understand the opportunities and challenges of working in a diverse, inner city area
• Commitment to reducing health inequalities and proactively working to reach people from all communities
• Understanding how integrated working supports residents in a holistic way
• Awareness of frailty, long-term conditions, poor health and the complexities involved physical, emotional and social
• Knowledge of how health and social care works including primary care
• Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety

Desirable

• Knowledge of PCNs, Neighbourhood, locality and the borough of Tower Hamlets

Qualifications

Essential

• Educated to GCSE level (or equivalent by experience).
• NVQ Level 4/5 or equivalent.
• Demonstrable commitment to professional and personal development

Experience

Essential

• Worked in statutory or voluntary sector services
• Worked in supportive roles that involved direct contact with the public, their families or carers (in a paid or voluntary capacity)
• Worked in multi team environments
• Been involved in or provided coordination support for MDTs

Desirable

• Worked in a Care Coordinator role or across adult health and social care or Public health improvement

Skills

Essential

• Able to communicate effectively, both verbally and in writing, with residents, their families, carers, community groups, partner agencies and stakeholders
• Ability to use EMIS, Microsoft Office applications Word, Excel, PowerPoint, Outlook
• Ability to collate and analyse data and use tools to measure impact
• An understanding of the importance of accurate and timely documentation, confidentiality, and safe information sharing
• Ability to listen, empathise with people and provide person- centred support in a non-judgmental way
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
• Able to support people in a way that inspires trust, motivating others to reach their potential
• Commitment to collaborative working and the ability to maintain effective working relationships
• Personal accountability, emotional resilience and works well under pressure
• Ability to identify risk and assess/manage risk when working with individuals
• Ability to work flexibly and enthusiastically within a team or on own initiative

Desirable

• Proficient speaker of another language to aid communication with people in the community for whom English is a second language
• A strong awareness and understanding of when it is
• appropriate or necessary to refer people back to other health professionals/ agencies

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

Poplar & Limehouse Health & Wellbeing Network PCN

Address

21 Newby Place

London

E14 0EY

Employer's website

http://www.poplarandlimehousehealthnetwork.com (Opens in a new tab)