We are searching for a Frailty Navigator to join our Inner City PCN team.
You will be required towork across various locations in Gloucester. This will also include our InnerCity PCN Surgeries Gloucester Health Access, Pavilion and St James FamilyDoctors, Severnside Medical Practice and Kingsholm Surgery .
Working Hours:18.5 hours per week.
Interview date: Thursday 19thFebruary TBC
Applications may close early depending on response.
Main duties of the job
To proactively identify andwork with people living with moderate or severe frailty and/or dementia toprovide co-ordination and navigation of care and support across health, careand support services.
The Care Navigator will actas a central point of contact to ensure appropriate support is made availableto people and their carers; enabling them to understand and manage theircondition and ensuring their changing needs are addressed.
Provideadministrative support, working for the benefit of patients, providing andmaintaining high standards of care for patients health needs.
The post holderwill become an integral part of the PCN multidisciplinary team, workingalongside social prescribing link workers and other community providers toprovide an all-encompassing approach to personalised care.
The role isintended to support the Clinical Director and Business Manager to develop thePCN and achieve the PCN DES targets, undertaking a variety of projects andsupporting digital transformation as required.
The job isprimarily working with practices in the PCN and you will be required to travelindependently between practices and occasionally G DOCs offices in Gloucester,and to attend meetings etc., hosted by other agencies throughoutGloucestershire.
Reports to: the PCNBusiness Manager and the PCN Clinical Director.
Line Manager: PCN BusinessManager
About us
G DOC LTD is a unique, GP-owned organisation all GPsurgeries in Gloucestershire are our shareholders. We operate with anot-for-profit ethos, ensuring every decision and service is focused onimproving patient outcomes and reinvesting in local Primary Care across thecounty.
We directly manage several GP surgeries in Gloucesterand the Forest of Dean, providing patient-centred care to more than 45,000patients. We value continuity of care and practice teams are at the heartof all we do. In addition to our surgeries, we deliver a range of countywidecommissioned services designed to improve access, increase capacity, or providespecialist support. Our teams are committed to delivering sustainable,high-quality primary care while fostering innovation and collaboration acrossthe local health system.
By joining us, youll be part of an organisation thatputs people first supporting staff wellbeing, professional development, and acollaborative culture. Youll benefit from the stability, support, and careeropportunities of a larger organisation, while still working in close-knit,community-focused teams.
Job responsibilities
Duties
Assist practices to identify and work with frail/elderlypeople and their carers, to provide coordination and navigation of care andsupport across health and care services.
Case Identification:
Support the Frailty Practitioner as required to undertake digital riskstratification
Transpose data onto the Personalised Proactive Whiteboard (PPW), readyto enable care coordination
Support the Frailty Practitioner to triagepotential patients to determine who receives a Comprehensive GeriatricAssessment (CGA)
Support the Frailty Practitioner to determine whataction to take with those patients who do not receive a CGA, including ensuringactions are undertaken
Contribute to the completion of CGAs as determinedby the Frailty Practitioner, inputting the information gleaned into a digitaltemplate
PersonalisedCare and Support Planning:
Asdetermined by the Frailty Practitioner:
oEnsure each patient who has a CGA has aPersonalised Care and Support Plan (PCSP) that has been discussed and finalisedwith the patient and any carer/family; this will help to manage their needs andachieve better health and wellbeing outcomes
oEnsure a ReSPECT plan is completed for each patientwho has a CGA
General
Identifycarers and help them access services to support them, ensuring they are codedas a carer on the GP clinical system if they are a patient at the Practice
Provide a single point of contact to answerqueries, make and manage appointments, and ensure that people have good qualitywritten or verbal information to help them make choices about their care.
Assistpeople to access self-management education courses, peer support, healthcoaching and other interventions to enable them to better manage their healthand wellbeing.
Work closely with GPs and practice teams to supportthem to manage patients to develop individual personalised care and supportplans, ensuring appropriate support is made available to patients and carers,helping them to understand and manage their condition and ensure changing needsare addressed.
Review patients needs and help them access theservices and support they require to understand and manage their own health andwellbeing
Liaise and work with the ICB, practices, voluntaryand other organisations to implement patient services
Assist the Business Manager in collatinginformation for claims (e.g. ARRS, Care Homes, etc) and responding to queries
Monitor the PCNs generic mailboxes and respondappropriately to emails
Coordinate, organise and attend various MDTmeetings (e.g. Care Homes, Dementia, Respiratory and Pain Management).
Assist the Lead education GP to organise trainingincluding PLT sessions
Support the Business Manager to deliver keyprojects, including quality improvement projects. This includes the provisionof information and analysis using information, data, knowledge and technologysystems to inform and support PCN agreed initiatives and meet the needs of thelocal population.
Support the PCN Leadership team in the delivery ofthe DES specifications and support Quality and Outcome Frameworks.
Assess data, monitor the PCN dashboard and liaisewith the Digital and Transformation Leads, Practices, GPs and Nursing teams,with a view to achieving network targets and obtaining maximum investment andimpact funding
Attend meetings on behalf of the PCN
Take minutes of meetings as required.
Raise awareness of health promotion in practices,implementing, co-ordinating and supporting a variety of projects.
Assist the Clinical Director and Business Managerto coordinate the Covid Vaccination programmes across practices
Support the PCN practices, contributing to thedelivery of QOF and enhanced services.
Contributing to the management and development ofthe Primary Care Network, including the performance of work undertaken by thePractice as part of the PCN
Helping to ensure that the PCN remains safe andeffective, including by the use of clinical audit and learning from significantevents and complaints.
Working conditions
Frequent, prolonged VDU use
Time-pressured environment
High levels of accuracy and attention todetail essential at all times
Exposure to distressing situations andwritten material
Job Description forall G DOC workers
The job description for all G DOCworkers also forms part of your job description.
Person Specification
* An interest in working with older people
* Clear, polite telephone manner
* Polite and confident
* Flexible and cooperative
* Motivated
* High levels of integrity and loyalty
* Sensitive and empathetic in distressing situations
* Ability to work under pressure
Experience
* Experience of working with or supporting older people
* Experience of General Practice and/or Primary Care
* Previous experience in a GP practice or primary care.
* Experience of working with members of the public in a supportive role
* Understanding of Information Governance / data compliance
Other
* Evidence of continuing professional development
Skills
* Excellent communication skills (written and oral)
* If not already competent in the use of SystmOne, Office & Outlook, willing and able to undertake training
* Ability to follow policy and procedure
* Effective time management (Planning & Organising)
* Ability to work as a team member and autonomously
* Good interpersonal skills
* Understanding of confidentiality and data protection
* or willing and able to undertake training
* Competent in use of SystmOne
* Competent in the use of Office and Outlook
Qualifications
* GCSE English Grade 5 or above (or equivalent or higher qualification)
* GCSE Maths Grade 5 or above (or equivalent or higher qualification)
* NVQ Level 2/3 in Health and Social Care or equivalent.
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.
Business Manager - Gloucester Inner City PCN
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