Job responsibilities
The primary focus of this role is to
provide support to patients, aged 18 years and over, with a long term
condition, engaging patients in their care and encouraging improved results and
better health outcomes.
The role will
support the Practices within the PCN to deliver against the PCN Direct Enhanced
Service (DES) specification, working in partnership with clinical and
non-clinical colleagues, to ensure delivery of the best possible outcomes for
our patients. The work contributes to
supporting the Practices to meet QOF and KPI criteria.
The job description does not provide an exhaustive list of tasks and activities.
KEY RESPONSIBILTIES OF THE POST
Work with people, their families and
carers to improve their understanding of the patients condition and support
them to develop and review personalised care and support plans to manage
their needs and achieve better healthcare outcomes.
Help people to manage their needs
through answering queries, making and managing appointments, and ensuring
that people have good quality written or verbal information to help them make
choices about their care.
Work collaboratively with clinicians
and other primary care professionals within the PCN to proactively identify
and manage a caseload of patients with long-term conditions, and, where
appropriate, refer back to other health professionals within the PCN.
Support the coordination and
delivery of multidisciplinary teams within the PCN practices.
Raise awareness of how to identify
patients who may benefit from shared decision making and support PCN staff
and patients to be more prepared to have shared decision-making
conversations.
Work with people, their families,
carers and healthcare team members to encourage effective help-seeking
behaviours.
Support the PCN in developing
communication channels between the practices, people and their families and
carers and other agencies.
Conduct follow-ups on communications
from out of hospital and in-patient services.
Maintain records of referrals and
interventions to enable monitoring and evaluation of the service.
Support practices to keep care
records up-to-date by identifying and updating missing or out-of-date
information about the persons circumstances.
Contribute to risk and impact
assessments, monitoring and evaluations of the service.
Work with commissioners, integrated locality teams and other agencies to
support and further develop the role.
MAIN DUTIES
1. Enable access to personalised care
and support
a. Take referrals for individuals or
proactively identify people who could benefit from support through care co-ordination
b. Have a positive, empathetic and
responsive conversation with the person and their family and carer(s) about
their needs
c. Work towards increasing patients
understanding of how to manage and develop health and wellbeing through
offering advice and guidance
d. Develop an in-depth knowledge of the
local health and care infrastructure and know how, and when, to enable people
to access support and services that are right for them
e. Use tools to measure peoples levels
of knowledge, skills and confidence in managing their health and to tailor
support to them accordingly
f. Support people to develop and
implement personalised care and support plans
g. Review and update personalised care
and support plans at regular intervals
h. Ensure personalised care and support
plans are communicated to clinicians and any other professionals involved in
the persons care and uploaded to the relevant online care records, with
activity recorded using the relevant SNOMED codes
2. Coordinate and integrate care
a. Making and managing appointments for
patients, related to primary, secondary, community, local authority, statutory,
and voluntary organisations
b. Help people transition seamlessly
between secondary and community care services, conducting follow-up
appointments, and supporting people to navigate through the wider health and
care system
c. Refer onwards to social prescribing
link workers and health and wellbeing coaches where required
d. Regularly liaise with the range of
multidisciplinary professionals and colleagues involved in the persons care,
facilitating a coordinated approach and ensuring everyone is kept up to date so
that any issues or concerns can be appropriately addressed and supported
e. Actively participate in
multidisciplinary team meetings in the PCN as and when appropriate
f. Identify when action or additional
support is needed, alerting a named clinical contact in addition to relevant
professionals, and highlighting any safety concerns
g. Record what interventions are used to
support people, and how people are developing on their health and care journey
h. Keep accurate and up-to-date records
of contacts, appropriately using GP and other records systems relevant to the
role, adhering to information governance and data protection legislation
i. Work sensitively with people, their
families and carers to capture key information, while tracking of the impact of
care coordination on their health and wellbeing
j. Encourage people, their families and
carers to provide feedback and to share their stories about the impact of care
coordination on their lives
k. Record and collate information
according to agreed protocols and contribute to evaluation reports required for
the monitoring and quality improvement of the service
3. Professional development
a. Work with a named clinical point of contact
for advice and support
b. Undertake continual personal and
professional development, including mandatory training, taking an active part
in reviewing and developing the role and responsibilities, and provide evidence
of learning activity as required
c. Adhere to organisational policies and
procedures, including confidentiality, safeguarding, lone working, information
governance, equality, diversity and inclusion training and health and safety
4. Miscellaneous
a. Establish strong working
relationships with clinicians and practice teams and work collaboratively with
other care coordinators, social prescribing link workers and health and
wellbeing coaches, supporting each other, respecting each others views and
meeting regularly as a team
b. Act as a champion for personalised
care and shared decision making within the PCN
c. Demonstrate a flexible attitude and
be prepared to carry out other duties as may be reasonably required from time
to time within the general character of the post or the level of responsibility
of the role, ensuring that work is delivered in a timely and effective manner
d. Identify opportunities and gaps in the service
and provide feedback to continually improve the service and contribute to
business planning
e. Contribute to the development of
policies and plans relating to equality, diversity and reduction of health
inequalities
f. Work in accordance with the practices and
PCNs policies and procedures
g. Contribute to the wider aims and
objectives of the PCN to improve and support primary care
h.
Ability to cope with challenging and stressful situations
5. Clinical skills
a. Obtaining baseline observations for cohort of
patients with long-term conditions
b. Sample bloods, and process urine samples,
relevant to cohort of patients related to annual review, and ongoing
management, of long-term conditions
c. Undertaking other relevant tests, such as
diabetic foot checks and spirometry, etc, when suitably trained and within own
competency for cohort of patients with long-term conditions
COMMUNICATION
Communicate
effectively to overcome communication barriers with patients.
Have
the ability to communicate effectively with a wide range of people both
verbally and written.
To
source, develop and manage a range of contact details and sources of
information and services relevant to the local community and to make this
accessible to other PCN staff.
CONFIDENTIALITY
The
post holder must maintain strict confidentiality in all matters relating to
patients, their families, and carers, as well as organisational and staff
information. Information obtained in the
course of duties must not be disclosed to any unauthorised person or used for
personal gain. This includes verbal,
written, and electronic records. All
patient information must be handled in accordance with current data protection
legislation, confidentiality policies, and professional codes of practice. Breaches of confidentiality will be regarded
as a serious disciplinary matter.
EQUALITY & DIVERSITY
The
post holder will support the equality, diversity and rights of patients, carers
and colleagues, acting in a way that recognises the importance of peoples
rights, respecting their privacy and dignity.
HEALTH & SAFETY
To
take reasonable care for the health and safety of yourself and other people who
may be affected by your actions or omissions
Identify
risks involved in work activities and undertake activities in a way that
manages any risk
Be aware of
site health and safety policies and how to report incidents
