Job responsibilities
Main Duties
Support
the Enhanced Health in Care Homes (EHCH) multi-disciplinary (MDT) with day to
day duties
To
work as a key member of the team to help create and get agreement on the
structure and processes to support effective MDT meetings
To
liaise with the registered GP and other practice-based staff in addition to all
other providers and services utilising, where appropriate, a multi-disciplinary
approach.
Support
people to improve and maintain their mental, physical, behavioural health and
well-being, promoting health and preventing ill health
To
recognise changes in a patients condition/deterioration which require the
intervention of others and know when to refer to the supervising Registered
Nurse and other senior colleagues for reassessment of patient care.
To
recognise and work within the limits of their own competence.
To
ensure that high standards of nursing care are given and maintained, acting to
raise concerns when standards are not being maintained following local policy
and procedures.
To
be involved with practice initiatives to improve patient safety and care.
To
act as an advocate for the patient and family, including promoting and
protecting their interests, privacy, rights, equality and inclusion.
To
implement and review individual care plans, self-management plans and to agree
trigger thresholds to contact the multi-disciplinary team.
Provide
enhanced support to Nursing and Residential Care homes with a focus on
strengthening relationships and improving access through information sharing,
education and advice.
To
ensure all residents of Nursing and Residential Care homes have care plans
(including dementia where needed) and to provide a holistic review of all
people in these homes with updates of their care plans.
Communicate
any care plans to the GP and any other members of the EHCH multi-disciplinary
team and stakeholders involved in the persons care and upload to the relevant
records.
Act
as a contact to assist with case management of patients at risk of admission,
identifying sources of support in liaison with case managers.
To
provide support to individuals, their families and carers to take control of
their health and well-being, live independently and improve their health
outcomes, as a key member of the PCN multi-disciplinary team.
To
provide co-ordination and navigation with the aid of digital tools for people
and their carers across health and care services.
To
attend MDT meetings as appropriate.
Maintain
accurate and up to date records of patient contacts using GP clinical systems
and other IM & T systems relevant to the role
Support
the Clinical Director and member practices in the delivery of the PCN DES
specifications.
Administrative Duties
To
ensure that actions points identified with the MDT are recorded and
followed, upping risk-profiling strategies and tools to identify at risk
patients, including those patients who have multiple hospital admissions,
ED attendances and unplanned out of hours care, and implement an agreed
structured process on how this information will be fed into MDTs.
To
work with the wider MDT to identify appropriate case managers for high risk
patients to ensure that patients are reviewed and anticipatory care plans
are developed.
Ensure
that all patients Care Plans, Treatment Escalation Plans, DNARs and
associated reviews and patient-related correspondence are available at the
MDT meetings, liaising with all agencies as appropriate, access and
auditing IT systems to ensure relevant information is available. The need to work closely with the PCN
Care Co-Ordinators is key to this role.
To
liaise with acute hospitals regularly, cross referencing admission data
with the at risk list, and co-ordinating the sharing of key information
between the acute hospitals teams, care/nursing homes and the clinical lead
of the EHCH team.
Under
the guidance of the supervising Registered Nurse, assist with the discharge
process to reduce length of stay in the acute/community hospital setting.
Other responsibilities
To
assist the PCN in setting and realising the PCN vision and values
To
play a role in the delivery of high-quality primary health care services
Maintain
a working relationship with local health and care providers to enable
service delivery of mutual benefit and build a network and knowledge of
referral routes to and from service providers.
To
establish and maintain effective liaison with stakeholders including
health, voluntary, social and education resources, attending relevant
meetings as necessary.
Refer
patients and/or introduce them to appropriate organisations within the PCN
footprint and nationally (where appropriate), eg voluntary, statutory
(local authority) and local NHS organisations.
To
represent the PCN in cross-organisation meetings when agreed, eg locality/CCG
meetings.
Collate
feedback/analysis data on behalf of the PCN to report to the PCN Board and
CCG/NHSE as required
Support
the PCN Manager in providing KPI reports for submission as requested.
To
be familiar with and follow PCN and practice policies and procedures as
appropriate.
To
have due regard for own personal safety and that of learners, patients and
carers, in particular have regard to moving and handling regulations, restraining policies and
ensure the safe positioning of self and others.
To decide work priorities for own work area, balancing
responsibilities and changing priorities to meet deadlines, ensuring these
remain in accordance with those of the service as a whole.
Support, supervise and act as a role model to nursing
associate students, health care support workers and those new to care
roles, reviewing the quality of care they provide, promoting reflection and
providing constructive feedback.
Support service and practice development to meet the needs of
the local population.
Be flexible and response to changing requirements
Be able to work using own initiative as well as being part of
a team.
As this is a new and evolving role, this
is not an exhaustive list of duties and responsibilities, and the post holder
may be required to undertake other duties that fall
within the grade of the job, in discussion with their line manager.
The content of this job description will
be reviewed regularly in the light of changing service
requirements as First Coastal PCN evolves and any such changes will be
discussed with the post holder.
CONFIDENTIALITY
In the course
of seeking treatment, patients entrust us with, or allow us to gather sensitive information in relation to
their health and other matters. They
do so in confidence and have the right to expect that staff will respect their
privacy and act appropriately.
In the performance of the duties outlined in
this job description, the post-holder may have access to confidential
information relating to patients and their carers, practice staff and other
healthcare workers. They may also have
access to information relating to the PCN as a business organisation. All
such information from any source is to be regarded as strictly confidential.
Information relating to patients, carers,
colleagues, other healthcare workers or the business of the PCN may only be
divulged to authorised persons in accordance with the employing practice
policies and procedures relating to confidentiality and the protection of
personal and sensitive data.