PCN Learning Disability Care Coordinator

Job description

Job responsibilities

The post holder work closely with GPs and other Primary Care professionals within the PCN to identify and manage a caseload of patients with a Learning Disability. Work with people and their carers and primary care staff to organise and prepare for Annual Health Checks, enabling them to be actively involved in managing their care and supported to make choices that are right for them. Help to connect patients and their carers with relevant services, ensuring that reasonable adjustments are made that facilitate improved access to services, and promote optimum outcomes for the person. Focus delivery of this comprehensive model to reflect local priorities, promote inclusion and reduce health inequalities. Identify and report on key themes and issues to inform the strategic approach to service development. Support practices within the PCN to reach 80% and above of annual health checks for LD patients. Support practices to record and code preferred communication methods, reasonable adjustments and key carers/support networks in line with the Accessible Information Standard (2016) and Equality Act (2010). Identify barriers to accessing healthcare and work with practices, patients, families and carers to develop solutions that improve access to services. Promote and support engagement with Learning Disability Annual Health Checks - LDAHCs, including preparing patients and carers for appointments, reviewing attendance and following up non-attenders to reschedule where appropriate. Work with clinicians, patients and carers to develop and maintain personalised care plans and Health Action Plans - HAPs following annual health checks. Coordinate care across primary care, community learning disability teams, specialist services and acute care to ensure joined-up support. Promote the use of communication and hospital passports, and ensure patients have access to clear, accessible information to support informed choices about their care. Support patients to access screening, immunisations, self-management programmes, peer support, and other health and wellbeing services, including personal health budgets where appropriate. Work with social prescribing link workers, health and wellbeing coaches and other PCN roles to provide coordinated support across health and care services. Support the organisation and coordination of Best Interest Decision Making meetings and multidisciplinary team meetings when required. Identify unpaid carers and ensure they are appropriately recognised, coded and signposted to support services. Monitor patient needs and escalate concerns, safeguarding issues or risks to the appropriate clinical lead or professional in a timely manner. Use EMIS searches and reporting tools to track patients eligible for an LDAHC and track progress across the PCN. Monitor uptake and outcomes of annual health checks and produce reports to support service improvement. Analyse data to identify gaps in care, inequalities in access, and opportunities to improve patient engagement. Work independently within the scope of the role while seeking supervision or clinical guidance when necessary. Support wider PCN population health initiatives, including coordination of care for other vulnerable or at-risk groups such as people living with Serious Mental Illness - SMI. Monitor using defined tools, the outcomes and impact of care coordination on health and wellbeing. Actively seek feedback from people, their families and carers about the impact of care coordination. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning. Contribute to risk and impact assessments, monitoring and evaluations of the service. Work with practices and PCN leadership to develop targeted initiatives to improve coverage and quality of care.

Person Specification

Experience

Essential

• Knowledge of national priorities to improve outcomes for people with a learning disability
• Knowledge of how the NHS works, including primary care and PCNs
• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience of working within multi-professional team environments
• Experience or training in personalised care and support planning
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
• Able to work without day to day supervision
• Ability to identify risk and assess / manage risk when working with individuals,
• Ability to recognise and work within limits of competence and
• seek advice when needed

Desirable

• Experience of working with people with a learning disability
• or additional care needs due to cognitive impairment and their
• carers
• Experience of providing motivational coaching to support peoples behaviour change

Qualifications

Essential

• GCSE grade A-C in Maths
• & English or skills level 2 in Maths
• & English or equivalent

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

Malling PCN

Address

Larkfield Health Centre

Martin Square

Larkfield

Aylesford

Kent

ME20 6QJ

Employer's website

https://www.mallingpcn.co.uk/ (Opens in a new tab)