Job responsibilities
Description of role/ core
responsibilities
The post holder will:
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.
Key
working relationships
Patients,
carers and family members
PCN
Board of Directors
HIOW
Clinical Lead for Learning Disability and Autism
GP Practice
LD champions
GP
Practice Safeguarding Leads.
Community
Learning Disability Team
Secondary
Care Learning Disability Team
Wider
community and secondary care services
Neighbourhood
Teams
Social
Prescribing Link Workers
Voluntary,
Community and Social Enterprise (VCSE) Services
Social
Care Services
Community
pharmacists and support staff
Screening
and Immunisation Leads
Job
Responsibilities
Service Delivery
Proactively identify and work with
a cohort of people to support their personalised care requirements, using the
available decision support aids.
Support the Practice to establish
preferred means of communication to comply with The Accessible Information
Standard 2016 and ask about Reasonable Adjustments to meet The Equality Act
2010, to ensure that these are documented/coded and flagged correctly.
Establish who is the persons main
support and support the practice to ensure this is documented and coded
correctly.
Identify barriers to accessing
health care services, and plan actions and initiatives to overcome and assist
easier access to services.
Work with people, their families,
and carers to improve their understanding of the Learning Disability Annual
Health Check (LDAHC).
Work with Practices, people and
their families and carers or other support services to prepare for the LDAHC.
Review attendance to AHC
appointments and follow up those which have not attended or not been supported
to attend and support to reschedule as appropriate.
Bring together a persons
identified care and support needs and support them to explore their options
with the clinicians to produce a single personalised care and support plan: The
Health Action Plan (HAP).
Help patients and their carers
prepare for conversations they have with Primary Care professionals, ensuring
that their changing needs are addressed.
Follow
up on AHC appointment to ensure patients and carers have the support to ensure
quality health outcomes.
Support the interface between
primary care services, specialist community services and acute services,
thereby ensuring that people with a learning disability can enjoy good health
and receive appropriate treatment when necessary.
Develop plans to meet the
additional health needs of people with a learning disability who come from
ethnic communities that experience health inequalities.
Promote and encourage the use of
client held information (communication/ hospital passports), for when patients
access healthcare services. Support development of communication/hospital when
needed.
Help people to manage their needs,
answering their queries and supporting them to make appointments.
Raise awareness of shared decision-making
and decision support tools and assist people to be more prepared to have a
shared decision-making conversation.
Ensure that people have good
quality, accessible information to help them make choices about their care.
Assist people to access
self-management education courses, peer support or interventions that support
them in their health and wellbeing.
Explore and assist people to
access personal health budgets where appropriate.
Provide coordination and
navigation for people and their carers across health and care services,
alongside working closely with social prescribing link workers, health and
wellbeing coaches and other primary care roles.
Support the coordination and
delivery of best interest decision making meetings & Multi-disciplinary team
meetings within PCNs.
Promote and enable access to
screening and immunisation programmes.
Identify unpaid carers and help
them access services to support them. If the carer is a patient at a practice
within the PCN, ensure they are correctly coded.
Identify when action or additional support is
needed, alerting timely a named clinical contact in addition to relevant
professionals, and highlighting any safety concerns.
Identify and raise any issues or concerns relating to
care provision.
Work independently on a day to day basis, making
decisions within scope of role and actively seek supervision where required.
Clinical (dependant on experience and
Training)
Undertake part one of the LD annual health check
Phlebotomy
Record height, weight, blood pressure, pulse and
basic observations
Urinalysis
Communication
and record keeping
Develop strong working relationships with GPs and
practice teams and other professionals Work collaboratively with the Community
Learning Disability team.
Ensure that all relevant professionals are kept up
to date so that any issues or concerns can be appropriately addressed and
supported.
Proactively conduct follow-ups on communications
from out of hospital and in-patient services.
Actively participate in multidisciplinary team
meetings in the PCN when appropriate.
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.
Maintain records of referrals and interventions to
enable monitoring and evaluation of the service.
Provide feedback to relevant stakeholders about
service progress.
Service Development
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 any health trends/issues and report to the LDA
Clinical Lead to enable system learning and action.
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 commissioners, integrated locality teams
and other agencies to support and further develop the role.
Ensure that deaths of people with a Learning
Disability (LD) registered at the practices are reported to LeDeR.
Support the induction of new in post LD
Co-ordinators.
