Job summary
The post-holder will
help manage the frail patient population of Crossley Street Surgery, including
patients who are either housebound or resident of local Care Homes. This will involve helping to co-ordinate the achievement
of the Leeds ICB (Integrated Care Board) Enhanced Frailty Scheme targets. These will involve completing annual
personalised care planning frailty reviews for the severely frail, including
data gathering, completing relevant questionnaires and the frailty review
template, and liaising with carers. The
post-holder will help identify frail patients in need of further support, and
help the practice maintain an up-to-date frailty register. Good awareness of local community, primary
care and hospital services will be needed to enable appropriate referrals and
signposting to other Allied Health Professionals as appropriate and expected to
build relationships with local voluntary sector and social care to achieve
this. Simple observations will be
expected following suitable training if needed. These may include, but are not
limited to, checking blood pressure, pulse rate, urinalysis, and temperature. Ability to perform phlebotomy is expected and
training will be offered if required.
Main duties of the job
To
work alongside the triaging GP to contact patients and book suitable
appointments.
Management
and completion of annual frailty reviews.
Work
with patients, 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
patients 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, using tools to
understand peoples level of knowledge, confidence in skills in managing their
own health.
Work
collaboratively with primary care clinical and non-clinical professionals
within the practice to proactively identify and manage a caseload. This would
include liaising with patients to complete tasks directed by clinicians. This
could include checking how patients are adhering to their management plans and
feeding back to the clinician or supporting with liaising with other
organisations.
Assist
patients to access self-management education courses, peer support or
interventions that support them in their health and wellbeing and increase
their Activation level.
About us
Semi-rural, PMS, SystmOne, practice of over 12,000 patients
working from a modern purpose-built premises.
Training practice - 5 trainees, and wide multidisciplinary team
including a PCN pharmacy team and in-house pharmacy.
Progressive practice working with New Models of Care, in the
Wetherby Primary Care Network.
Job description
Job responsibilities
Provide
coordination and navigation for patients and their carers across health and
care services, working closely with social prescribing link workers, health and
wellbeing coaches, and other primary care professionals; helping to ensure
patients receive a joined-up service and the most appropriate support.
Raise
awareness of how to identify patients who may benefit from shared decision
making, and support staff and patients to be more prepared to have shared
decision-making conversations.
Explore
and assist patients to access a personal health budget where appropriate.
Work
with people, their families, carers, and healthcare team members to encourage
effective help-seeking behaviours.
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 patients circumstances.
Support
the practice to identify and screen patients who may be severely frail to
enable them to access targeted support.
This will include running reports, verifying data, and identifying
potential individuals requiring support from the wider team.
Work
flexibly to meet the needs of patients and be able to adapt to change.
To
undertake any other duties, appropriate to the purpose of the job as may be
agreed by the post holder.
Attend
practice Palliative Care Meetings to assist with writing up notes for patients
palliative care plans, allowing the leading GP to focus on leading the meeting.
Complete
SMI annual reviews i.e., physical health check-ups for those on the practice
Severe Mental Illness registers.
Complete
Learning Disability Health checks including Health Action Plans alongside appropriate
GP/Nursing input.
Support
specialist GP memory clinics at the practice, for example telephoning patients
and carers to ensure they have not forgotten appointment details, in addition
to providing administrative support as required.
Assist
with aspects of the Quality and Outcomes Framework (QoF) and Investment and
Impact fund (IIF) workstreams.
.
Job description
Job responsibilities
Provide
coordination and navigation for patients and their carers across health and
care services, working closely with social prescribing link workers, health and
wellbeing coaches, and other primary care professionals; helping to ensure
patients receive a joined-up service and the most appropriate support.
Raise
awareness of how to identify patients who may benefit from shared decision
making, and support staff and patients to be more prepared to have shared
decision-making conversations.
Explore
and assist patients to access a personal health budget where appropriate.
Work
with people, their families, carers, and healthcare team members to encourage
effective help-seeking behaviours.
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 patients circumstances.
Support
the practice to identify and screen patients who may be severely frail to
enable them to access targeted support.
This will include running reports, verifying data, and identifying
potential individuals requiring support from the wider team.
Work
flexibly to meet the needs of patients and be able to adapt to change.
To
undertake any other duties, appropriate to the purpose of the job as may be
agreed by the post holder.
Attend
practice Palliative Care Meetings to assist with writing up notes for patients
palliative care plans, allowing the leading GP to focus on leading the meeting.
Complete
SMI annual reviews i.e., physical health check-ups for those on the practice
Severe Mental Illness registers.
Complete
Learning Disability Health checks including Health Action Plans alongside appropriate
GP/Nursing input.
Support
specialist GP memory clinics at the practice, for example telephoning patients
and carers to ensure they have not forgotten appointment details, in addition
to providing administrative support as required.
Assist
with aspects of the Quality and Outcomes Framework (QoF) and Investment and
Impact fund (IIF) workstreams.
.
Person Specification
Qualifications
Essential
- Educated to GCSE level or equivalent
- GCSE Mathematics & English (C or above)
- Experience of working with the general public
- Experience of establishing effective office administrative systems
- Experience of working in a health care setting
- Excellent communication skills (written and oral)
- Excellent IT skills
- Clear, polite telephone manner
Desirable
- NVQ Level 3 in Health and Social Care
- ECDL or other equivalent IT qualification
- Understanding of the current issues facing the NHS including Primary Care Networks
Person Specification
Qualifications
Essential
- Educated to GCSE level or equivalent
- GCSE Mathematics & English (C or above)
- Experience of working with the general public
- Experience of establishing effective office administrative systems
- Experience of working in a health care setting
- Excellent communication skills (written and oral)
- Excellent IT skills
- Clear, polite telephone manner
Desirable
- NVQ Level 3 in Health and Social Care
- ECDL or other equivalent IT qualification
- Understanding of the current issues facing the NHS including Primary Care Networks
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.
