Job responsibilities
Job Purpose
The main objectives of the role are:
- To support delivery of the PCNs contractual requirements
- To support individuals identified as frail or at risk of frailty to manage their health and wellbeing
- To work both as part of the general practice team and a wider multi-disciplinary team, playing a role in coordinating care and support to individuals
- They will respond to referrals from GP surgeries or Care Homes supporting the arrangements for appropriate care and ensuring that unplanned, changing needs are addressed and that individuals are accessing appropriate support either from statutory or third sector services
Key Relationships
- Clinical Director
- PCN Management Team
- PCN Care Coordination Team
- PCN Clinical Team
- GPs in PCN Member Practices
- Practice Managers in PCN Member Practices
- PCN Care Homes
- Mersey Care Community Teams
- Social Prescribing Link Workers (SPLWs)
- Health and Wellbeing Coaches (HWBC)
Core Duties
- To support the Learning Disability Health Check Process
- To deliver Learning Disability Health Checks
- To support active case finding of patients with undiagnosed Cardiovascular disease
- To deliver blood pressure review clinics, ensuring the hypertension protocol is adhered to at all times
- To deliver cardiovascular disease prevention health checks (NHS Health Check) to patients within the PCN population, identifying those who require further intervention and support (e.g. pre-diabetes, statin therapy, weight management etc)
- To support and deliver vaccination clinics to patients (e.g. shingles, influenza pneumococcal) with the support of a clinical supervisor
- To refer patients to social prescribing link workers for support with non-medical holistic support, thus helping the PCN to achieve its objectives in referrals to SPLWs
- To conduct home visits appropriate to the competency to ensure the health and wellbeing of the patient population
Care Homes
- To visit and support patients in Care Home settings to assess whether there are any unmet health or care needs, including after discharge from hospital
- To complete holistic person-centred care planning, commencing the CGA process
- Communicate regularly with Care Homes to establish if there are new residents or residents recently discharged from hospital and commence the CGA process or coordinate the review of existing CGA
- Where unmet are identified to complete relevant referrals into wider clinical and third sector services
- To coordinate and attend the weekly PCN Care Home MDT meetings
Other Duties
- Work within all relevant service policies and procedural guidelines
- Maintain administration systems and workspace in a clean and tidy condition
- Work flexibly to meet the needs of the PMO
- Develop own knowledge to meet own objectives and changes in service
- Operate a high standard of probity
- Undertake any other duties appropriate to the grade and purpose of the role as may be agreed between the post holder and their line manager
Communication
- Build and communicate effective working relationships within the PMO, across the PCN Member practices and with a wide array of statutory and voluntary organisations for the benefit of patient care and to facilitate good working relationships
- Participate in team meetings
- Recognise the roles of other colleagues within the organisation and their role in patient care
- Demonstrate the use of appropriate communication to gain the co-operation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals, other NHS/private organisations)
- Demonstrate ability to work as a member of a team
- Promote effective communication and relationships within the team
- Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary
Managing Self and Others
- Manage own time, workload and resources effectively
- Work within the limits of your own competency, seeking advice or support when needed
- Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the service performance
- Assess own performance and take accountability for own actions, either directly or under supervision
Manage and Use Information
- Alert other team members to issues of quality and risk
- Assess own performance and take accountability for own actions, either directly or under supervision
- Effectively manage own time, workload and resources
- Make effective use of up-to-date information technology in order to collate accurate and timely information as and when required by the PMO
Confidentialty
In the course of seeking treatment, patients entrust us with and allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff respect their privacy and act appropriately.
In the performance of the duties outlined in this Job Description, the post holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the services business affairs. All such information is to be regarded as strictly confidential.
Information relating to patients, carers, colleagues, other healthcare workers or the business of the service may only be divulged to authorised persons in accordance with the service policies and procedures relating to confidentiality and the protection of sensitive data.
The post holder will be expected to comply with all aspects of the Data Protection Act.
Equality and Diversity
West Knowsley PCN is committed to achieving equality of opportunity for all staff and for those who access services. You must work in accordance with equal opportunities policies and procedures and promote the equality and diversity agenda of the service.
Health and Safety
Each member of staff is responsible for ensuring that they carry out the duties of their post in accordance with all appropriate Health and Safety legislation, guidance and procedures and they do not, by any act or omission on their part, create a threat to the Health and Safety of any other person.
Records Management
The post holder has responsibility for the timely and accurate creation, maintenance and storage of records in accordance with service policy, including email documents and with regard to the Data Protection Act, The Freedom of Information Act and any other relevant statutory requirements.
Clinical Governance
The post holder will be expected to participate in clinical governance activities to assist the service to provide high quality services.
Prevention and Control of Healthcare Associated Infection
The post holder is expected to comply with Service Infection Control Policies and conduct themselves at all times in such a manner as to minimise the risk of healthcare associated infection.
Smoking
The service operates a non-smoking policy.
Policies and Procedures
Service employees are expected to follow service policies, procedures and guidance as well as professional standards and guidance.
External Interests
Each member of staff is responsible for ensuring that any external interest they have does not conflict with the duties of their posts and they must disclose the external interest if this is likely to occur, or if they are in doubt about a possible conflict of interest.
Mandatory Training
Each member of staff has a statutory obligation to attend mandatory training. It is the responsibility of each member of staff to ensure that they comply with this legal requirement.
Flexibility
This job description is intended to act as a flexible guide to the duties of the post and therefore will require revision in consultation with the post holder to reflect the changing requirements of the post, to enable the service to achieve its goals and objectives.
Safeguarding
- The service is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults and expect all staff to share its commitment
- All Partners and staff share this responsibility and should comply with current policies, undertaking the appropriate level of training for the role
- If employees have reason for concern that a patient is at risk they should escalate this to an appropriate person (for example, Practice Manager, Safeguarding Lead GP, PCN Clinical Director)