LS25/26 PCN Proactive Frailty Care Coordinator in Leeds

LS25/26 PCN Proactive Frailty Care Coordinator

DUTIES AND AREAS OF RESPONSIBILITY

Support the PCN in bringing together all of a patients identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the patient. This may include having a caseload of patients. Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system Support the frailty team in identifying appropriate patient cohorts for targeted intervention Partake in multidisciplinary meetings across local care organisations identifying patients in need of review and collating any information required to facilitate their review prior to the meeting. Provide admin support to multidisciplinary meetings including taking minutes. Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists, and other support staff from within the PCN practices or from other provider organisations Undertake delegated clinical procedures within own skills and competence when required (depending on experience and qualifications) Assist patients and carers in managing their own needs, answering their queries, and supporting them to address their needs Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care Raise awareness of shared decision making and decision support tools, and assist patients to be more prepared for shared decision-making conversations To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with professionals from the MDT Work in partnership with key providers in the local community to enable improved access to services for patients Support patients to self-manage conditions. Support patients to access appropriate benefits where eligible Actively engage with, assist and provide advice to carers, to enable them to sustain their caring role escalating any concerns to the practice when required Work with practices to support delivery of any national and local targets with regard to the GP contract e.g. PCN DES Engage in delegated clinical tasks including but not limited to, venepuncture, observation monitoring, measuring, and ordering equipment, ear checks, supporting patients to manage e.g. inhaler technique Supporting families and carers to help effectively support the patient. SAFEGUARDING Identifies and takes appropriate safeguarding action when required in line with local policies Support the practices in safeguarding processes, knowing when to intervene. Ensuring patients are protected from harm, while protecting their human rights. Alert your line manager of any significant changes or events which relate to safeguarding Support safeguarding investigations where required

OTHER RESPONSIBILITIES

To assist the PCN Clinical Director(s) and board in setting and realising the PCN vision, mission, and business strategy. To play a role in the delivery of high-quality primary health care service. Maintain a working relationship with local health care providers enable service delivery and mutual benefit and build a network and knowledge of referral routes to and from service providers. To establish and maintain effective liaison with stakeholders including health, voluntary, social and education resources, attending relevant meetings as necessary Collate feedback/analysis data on behalf of the PCN to report to the PCN Board and CCG/NHSE as required Support the PCN Operational Manager in providing Key Performance Indicator (KPI) reports for submission as requested. Work in partnership with local providers and community groups to improve collaboration, co-ordination of care and support to the local population Attendance and contribution at relevant community meetings to represent the frailty team when required. Be responsible for the organisation, planning of own workload to meet set deadlines. Following PCN and practice policies and procedures as appropriate.

KEY WORKING RELATIONSHIPS

Frailty MDT Local Neighbourhood Team GP Practices with the PCN Practice Leaders (Partners and Practice Managers) PCN Social Prescribing Health and wellbeing team PCN Clinical Pharmacists PCN Clinical Director(s) and Operational Manager Adult Social Care Third sector partners