Job responsibilities
Role Objectives:
The post holder, working closely with the PCN team, GPs and
existing community services will:
Coordinate Multi-Disciplinary Team meetings for people living in
the community
Utilise Population Health Intelligence to proactively identify
patients at risk and work with the PCN team to enable the PCN team to deliver
personalised care
Utilise Population Health Intelligence tools where needed to
support other patients in the PCN.
Support the achievement of the IIF targets through reporting and
communication
Be responsible for daily updating of patients on e-HealthScope
Workflow to identify patient to support the PCN team with identifying community
pathways that might prevent hospital admission and for identifying potential
gaps in care
Be responsible for arranging, attending and minuting
Multi-Disciplinary Team Meetings
Proactively prepare any actions prior to the MDT meetings
ensuring all relevant clinicians are present
To record patient interventions on relevant electronic database
systems (e.g. SystmOne) and contribute to report generation, analysis and
production
Follow up on all forward actions resulting from MDT discussions
Be responsible for logging and making referrals
To contribute to the integration of health and social care by
maintaining up to date recording systems for all agencies within the PCN Team
and providing information to any member of the PCN Team in order to ease processes
and communication in agreement with data protection protocol
To be responsible for recording, reporting and producing
evaluation reports which will include evaluation detailing effectiveness
outcomes of new roles.
To be customer (patient, carer, GP) focused when representing
the service
To work collaboratively with other teams and services to
maintain an effective and efficient service
To offer appropriate support and guidance to patients and their
families/carers
To plan / organise work using own initiative, whilst being able
to work as a valuable member of a team
To have excellent IT skills, to include Microsoft Office,
Outlook and Excel
To undertake general office duties to support the role
To work effectively as part of a team to provide cover for Care
Coordination Teams when required and to be flexible regarding working hours to
meet the needs of the service
To ensure all electronic records are updated and complete within
the agreed time-scales
To use a range of verbal and non-verbal communication tools to
communicate effectively with patients, carers and families and colleagues.
Provide coordination of and participate in relevant internal and
external working groups and provide project advice, expertise and support where
requested.
Support the PCN team by inputting into the overall strategy
development and programming of work streams by applying knowledge and
understanding of programme and project management
Work with key personnel in the PCN to develop & support
collective general practice projects including areas of federated working
Work towards completing the appropriate training to deliver and
support the Comprehensive Model for Personalised Care
To participate in the review and appraisal process
To carry out any other reasonable duties as requested by a
manager to ensure quality of service
To participate in any relevant training/courses/conferences
Complete mandatory training
Use clinical systems for record keeping, audit and evaluation
Develop and implement data collection systems that will provide
accurate and timely data.
Maintain confidentiality
Professional Development /
Personal Performance
Identify learning needs, plan, implement and evaluate programmes
of education to meet identified need.
Establish own support mechanisms to enable structured
reflection, including supervision, development of supportive networks mentoring
and coaching.
Participate in and undertake supervision of colleagues on an
individual or group
Participate in the Divisional appraisal System and demonstrate
the achievement of agreed personal objectives.
SUPPLEMENTARY DUTIES AND
RESPONSIBILITES
Mobility
Employees may be required to work at any of the other sites
within the organisation subject to consultation. The organisation is in a
period of rapid change due to developments and rationalisation of services.
This will lead to modification of structures and job descriptions. The post
holder will be expected to co-operate with changes subject to consultation, at
any time throughout the duration of their contract
Health and Safety
Employees have a legal responsibility not to endanger
themselves, fellow employees and others by their individual acts or omissions.
The post holder is required to comply with the requirements of any policy or
procedure issued in respect of minimising the risk of injury or disease.
Data Protection and
Confidentiality
All employees are subject to the requirements of the Data
Protection Act 2018 and must maintain strict confidentiality in respect of
patient, client and staff records.
Safeguarding
Responsibilities
The organisation takes the issues of Safeguarding Children,
Adults and addressing domestic violence very seriously. All employees have a
responsibility to support the organisation in our duties by:
Attending mandatory training on Safeguarding children and
adults.
Making sure they are familiar with their and the organisations
requirements under relevant legislation.
Adhering to all relevant national and local policies,
procedures, practice guidance (e.g. LSCB Child Protection Procedures and
Practice Guidance) and professional codes.
Reporting any concerns to the appropriate authority.
Equality and Diversity
The organisation is committed to promoting equal opportunities
to achieve equity of access, experience and outcomes and to recognising and
valuing peoples differences. This applies to all activities as a service
provider, as an employer and as a commissioner.
Information Management and
Technology (IM&T)
All staff are expected to utilise the relevant national and
local IM&T systems necessary to undertake their role.
Flexible Working
The organisation is committed to offering flexible, modern
employment practices, which recognise that all staff need to strike a sensible
balance between home and work life. All requests to work flexibly will be
considered.
Resource Management
Ensure the effective and efficient use of physical and financial
resources, make recommendations regarding supplies and equipment
Freedom to Act
Adhere to organisations policies and procedures, guided by
occupational policies and procedures in primary and secondary care.
Maintain up to date skills and knowledge and maintain awareness
of professional issues.
Maintain a professional portfolio.
Works without supervision plans own workload, guidance sought if
required from line manager and colleagues.
The post holder should demonstrate good organization and time
management skills
Reasonable Adjustments
The organisation is seeking to promote the employment of
disabled people and will make any adjustments considered reasonable to the
above duties under the terms of the Equality Act 2010 to accommodate a suitable
disabled candidate.
The above is only an outline of the tasks, responsibilities and
outcomes required of the role. The job holder will carry out any other duties
as may reasonably be required by their line manager.
The job description and person specification may be reviewed on
an on-going basis in accordance with the changing needs of the PCN and the
Organisation.
Physical and Mental Skills
The post holder should be physically fit for the role with the
necessary keyboard and IT skills.
Required to communicate across the health community and with
patients / carers where the nature of the information given may be sensitive
and could be disputed.
The post holder should be empathetic and skilled in listening,
persuasion and negotiation, and recognises Care, Compassion, Courage,
Competency, Communication, and Commitment in their role.
Effort and Environment
Physical effort:
Frequent long periods of time spent writing up patient related
information within agreed time limits. There is a need for speed and accuracy.
This is a continuous requirement throughout each day.
Prolonged periods of time spent in a sitting position at a
computer screen when answering the telephone and writing clinical information
in patients notes at the same time.
Frequent periods through the day of standing and walking to
liaise with other Health and Social Professionals. The post holder is
occasionally required to lift equipment several times throughout the week e.g.
files or boxes or stationery.
The post holder is occasionally required to lift equipment
several times throughout the week e.g. files or boxes or stationery.
Mental Effort:
Prioritising work is essential, as often many tasks are required
to be undertaken simultaneously. The post holder is required to work under
pressure and meet deadlines.
Emotional Effort:
Potential distressing situations e.g. liaising with terminally
ill patients and their carers/families. Exposure to vulnerable groups.
Working Conditions
To function effectively across a variety of environments
Occasionally the post holder may be exposed to aggressive verbal
abuse/physical aggression from patients, relatives and other health and social
care professionals over the telephone or face to face.