Job responsibilities
Salary: based on indicative Agenda for Change Band 4
Interview: expected to take place week commencing 24 November 2025 at Creech Medical Centre
Key responsibilities
The aim of EHCH is to provide proactive and personalised healthcare for
people with multiple long-term conditions, including frailty and health
inequalities delivered through multi-disciplinary teams in local communities.
Working with clinicians to provide support in care homes with an emphasis on
self-management and prevention of avoidable illness, whilst, building a
long-term working relationship with care homes.
Provide coordination and navigation for health, social care and
neighbourhood services helping to ensure patients receive a joined-up service
and the most appropriate support.
Provide coordination of weekly care home rounds across the PCN.
Work collaboratively with GPs and other primary care professionals within
the PCN to proactively identify residents who would benefit from
Muli-Disciplinary Team review and where appropriate, refer to other health
professionals within the PCN / Neighbourhood.
Support the coordination, administrative tasks and delivery of
multidisciplinary teams with the PCN.
Support professional
meetings, inclusive of minuting the Multidisciplinary Team meeting and Multi
Agency Risk Meetings as required by the team.
Carry out holistic assessments to aid patients in managing any long-term
conditions they may have, supporting self-management and access to care.
Work closely with patient
families and or advocates to enable them to support their loved ones in
decision making and personalised care planning.
Support PCNs in developing communication channels between GPs and Care
Homes including in reaching into secondary care services and follow up post
discharge.
Liaise with key stakeholders
as needed for the collective benefit of the patient.
Maintain accurate and timely 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updating missing or out-of-date information about the patient's circumstances.
Contribute to risk and impact assessments, monitoring and evaluations of
the service.
Cross cover care-coordinators and administrative duties within the
Proactive Care Team as required by the service.
Key Tasks
1. Enable access to personalised care and support:
a.Take referrals for
individuals or proactively identify patients who could benefit from support through care coordination;
b. Support
patients to develop and implement personalised care and support plans;
c.
Review
and update personalised care and support plans at regular intervals;
d.
Ensure
personalised care and support plans are communicated to the GP and any other
professionals involved in the patient's care and uploaded to the relevant
online care records, with activity recorded using the relevant SNOMED codes;
2. Coordinate and integrate care:
a.
Help to
transition seamlessly between services and support them to navigate through the
health and care system;
b.
Refer
onwards to appropriate health and social care professionals where required;
c.
Facilitating
a coordinated approach to care and ensuring effective communication between
teams for accurate records;
d. Actively participate
in multidisciplinary team meetings in the PCN and individual practices as and
when appropriate. This may include minuting and administrative tasks that arise
from the meeting;
e.
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;
f.
Identify
when additional support is needed alerting a named clinical contact in addition
to relevant professionals and highlighting any safety concerns;
g.
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;
h.
Encourage
patients to provide feedback and to share their stories about the impact of
care coordination on their lives;
i.
Record
and collate information according to agreed protocols and contribute to
evaluation reports required for the monitoring and quality improvement of the
service;
j.
Run
necessary reports as required by the EHCH team;
k.
Complete
necessary administration responsibilities as required by the EHCH Team;
3. Professional
development:
a.
Work
with a named clinical point of contact for advice and support;
b.
Undertake
continual personal and professional development, 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 GPs, practice teams, care homes 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.
Duties
may vary from time to time without changing the general character of the post
or the level of responsibility;
h.
Contribute
to the wider aims and objectives of the PCN to improve and support primary
care;
i. To support in the delivery of the PCN Network DES,
enhanced services and other service requirements on behalf of the PCN;
Job Description Agreement
This Job Description is
flexible, and the post holder will be expected to undertake any other duties
appropriate to the role as may be required by the PCN. This Job Description is
subject to change from time to time with organisational need and the post holders
agreement should not unreasonably be denied.