Frailty Care Coordinator in Truro

Arbennek PCN is looking for an innovative and highly motivated person to join its team as a Frailty Care Coordinator. 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.

Main duties of the job:

• Proactively identify and work with a cohort of patients to support their personalised care requirements.
• Provide coordination and navigation support using digital tools to help patients access appropriate services.
• Develop and maintain personalised care and support plans based on an individual's needs and what matters to them.
• Promote preventative health care and continuity of care.

About us:

Arbennek PCN & INT is located in the central ICA within the Cornwall and Isles of Scilly Integrated Care System and has approximately 32,453 people registered from 4 GP Practices: Brannel Surgery, Clays Surgery, Probus Surgery and Roseland Surgeries.

Job responsibilities:

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 ongoing 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.

Key working relationships:

• Frailty GP lead
• Patients, patients' families and carers
• GPs, nurses and other practice staff
• Care home managers, clinicians, carers and staff
• 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 patient's 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.
• 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.
• Review discharge summaries and conduct post-discharge follow-up calls 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 tests from 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 the ability to independently travel essential in role delivery.

Administrative Responsibilities:

• 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. 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 meet service needs.

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.

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.

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.

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.

Person Specification:

• Qualified NVQ level 2 (or equivalent) Health and Social care
• Qualified NVQ level 3 (or equivalent) Health and Social care
• Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
• Experience of administrative duties
• Computer literate and proficient in the use of Microsoft packages and other software.
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
• Able to prioritise and manage own workload
• Excellent verbal and written communication
• Experience of taking Patient observation e.g. blood pressure, venepuncture, body temperature, respiratory rate and oxygen saturation
• Able to deal with service users sensitively
• Able to work as part of a team
• Strong analytical and judgement skills.
• Experience providing signposting and advice
• Conscientious, hardworking and self-motivated to work with minimal supervision
• Professional attitude and assertive approach
• Committed to development both personally and for the organisation
• Ability to meet deadlines and work under pressure
• Experience of developing and supporting PCSPs, TEPs and ACPs
• Experience of arranging meetings/minute taking
• Understanding of health and social care processes
• Experience of working with a Trauma led approach

Disclosure and Barring Service Check:

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.