Job responsibilities
Job Purpose
The Frailty Care Coordinator role is seen as a
critical and evolving post to support the development of a proactive frailty
service operating at Integrated Neighbourhood Team (INT) level.
The Frailty Care Coordinator will support multi-disciplinary
teams (MDTs) within the INT and PCN to deliver effective, co-ordinated and
personalised care for patients in care homes and for a cohort of elderly and
frail patients.
The post holder will work closely with the
multi-disciplinary team to support INT and PCN on-going patient case management
and to support patient cohorts which have been identified for support by the
INT and PCN. This will involve working with the GP surgeries and linking in
with a range of community health and social care services, care homes, the VCSE
and third party services.
The post holder will demonstrate excellent
organisational and communication skills, be flexible in their approach, able to
exercise initiative and demonstrate consistently high standards of
professionalism. The post holder must at all times be aware of the need for
confidentiality and integrity. They will also need a basic knowledge of Health
and Social Care terminology and eligibility criteria and current team
structures and pathways.
Key working relationships
Frailty GP lead
Patients, patients families and carers
GPs, nurses and other practice staff
Care home managers, clinicians, carers and staff
Frailty GP Lead, Case Manager and Geriatrician
Community nurses and other allied health professionals
Community pharmacists and support staff
Responsibilities underpinning the role
To assist the team to develop one single personalised
care and support plan for patients to be held on the patients medical records
and in the care homes. Holistically bring together all of a patients
identified care and support needs, and explore options to meet these with a
single personalised care and support plan (PCSP), in line with PCSP best
practice, based on what matters to the person.
To
develop and support patient Treatment Escalation Plans (TEPs) and Advanced Care
Planning (ACP).
Help
patients to manage their needs by answering queries, assisting with making/
managing appointments, and ensuring that patients have good verbal or written
information to help them make choices about their care.
Provide
coordination and navigation for patients and their carers across health and
social care services, working closely with social prescribing link workers and
other primary care professionals. Explore and assist people to access personal
health budgets or appropriate benefits where eligible.
Support
patients to utilise decision aids in preparation for a shared decision-making
conversation.
Work
with GPs and other primary care professionals and colleagues within the INT and
PCN to identify and manage a caseload of patients, and where required and as
appropriate, refer patients back to other health professionals within the INT.
Raise
awareness within the INT of shared decision making and decision support tools.
Raise awareness of how to identify patients who may benefit from shared
decision making and support INT staff and patients to be more prepared to have
shared decision-making conversations.
To act as first point of contact for professionals,
GPs, care homes, community services and the third sector across the INT.
Responsible for the organisation of MDT meetings and supporting
the coordination and delivery of MDTs within the INT and PCN.
Responsible
for a register of patients identified at INT MDT coordinating patient care
across services and the INT.
Review
discharge summaries and conduct post discharge follow up call to review patients
needs and arrange a package of care if needed.
Manage
the recall of patients in need of bloods/BPs and other diagnostic test for
medication reviews and/or green eclipse alerts supporting with patient
observations where necessary.
To
act as a support contact for elderly and frail patients.
To
support end of life care and palliative care.
To
provide support for patients with learning disabilities.
To
follow appropriate safeguarding procedures.
To
undertake patient observations blood pressure, venepuncture, body
temperature, respiratory rate and oxygen saturation.
To
support housebound and care home patients with ability to independently travel
essential in role delivery.
Administrative Reponsibilities
To work as a key member of the MDT to help support the
development of effective MDT meetings.
To
take a lead in IT ensuring all MDT staff have access to Microsoft Teams and
have adequate equipment to participate in video meetings.
Lead on the IT facilitation of the MDT meetings using
Microsoft teams including sending out invites to appropriate members of the
MDT.
To take minutes of MDT meetings and ensure that action
points identified are recorded and followed up within a set timescale.
Under guidance from their line manager take initiative
in the organisation and administration of MDT working to minimise the demands
upon the multidisciplinary team.
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 Anticipatory Care Plans,
diagnostics results and associated correspondence are available to the MDT,
liaising with all agencies as appropriate, accessing IT systems to ensure
relevant information is available
To liaise with acute hospitals and coordinate the
sharing of key information between the acute hospital teams and the MDT team.
Act
as a non-clinical contact for the care home to assist with case management of
patients at risk of admission; working with the ANP / GP to identify sources of
support in liaison with case managers.
To
accurately read code and update/maintain patients records for anticipatory
care.
To
update care plan templates within Systm1 ensuring accuracy with read codes
used.
Maintain
an accurate record of two week wait referrals for practice audits.
To
provide support with safeguarding admin (adults and child).
Under the guidance of case managers assist with the
discharge process to reduce length of stay in the acute / community hospital
setting
This list is not
exhaustive and may be subject to change
Workforce Responsibility
The post holder must remain up to date with mandatory
training as required
Environmental Factors
The post holder will be required to drive
The post holder may be required to undertake duties at
any location in the community in order to meets service needs
Concentration required for data analysis, tracking
patients and meetings, frequent interruptions requiring attention and
re-prioritisation of work
Input data for a significant period
Equal Opportunities
Arbennek Healthcare is committed to an equal opportunities policy
that affirms that all staff should be afforded equality of treatment and
opportunity in employment irrespective of sexuality, marital status, race,
religion/belief, ethnic origin, age, or disability. All staff are required to
observe this policy in their behaviour to fellow employees.
Confidentiality
All employees are required to observe the strictest confidence
with regard to any patient/client information that they may have access to, or
accidentally gain knowledge of, in the course of their duties.
All employees are required to observe the strictest confidence
regarding any information relating to the work of Arbennek Healthcare and its
employees. You are required not to disclose any confidential information either
during or after your employment with Arbennek Healthcare, other than in
accordance with the relevant professional codes.
Failure to comply with these regulations whilst in the employment
of Arbennek Healthcare could result in action being taken.
Data Protection
All employees must adhere to the Arbennek Healthcare Policy on the
Protection and use of Personal Information, which provides guidance on the use
and disclosure of information. The practices of North Cornwall Coast also have
a range of policies for the use of computer equipment and computer-generated
information. These policies detail the employees legal obligations and include
references to current legislation.
Health and safety
Arbennek Healthcare expects all staff to have a commitment to
promoting and maintaining a safe and healthy environment and be responsible for
their own and others welfare.
Risk Management
You will be responsible for adopting the risk management culture
and ensuring that you identify and assess all risks to your systems, processes
and environment and report such risks for inclusion within the risk register of
the practices of Arbennek Healthcare. You will also attend mandatory and
statutory training, report all incidents/accidents, including near misses, and
report unsafe occurrences as laid down within the Incidents and Accidents
Policy.
Other duties
The above job description is designed
to give an overview of the tasks and responsibilities for this position; it is
not intended to be exhaustive. The Strategic Manager will meet annually with
the post holder to review and ensure that this position remains relevant and in
accordance with the evolving needs of the PCN.