As part of the Chronic Disease Management team this role will focus on supporting those patients living with long term conditions such as Diabetes, Chronic Obstructive Pulmonary Disease, Asthma, Hypertension, Cardiovascular Disease etc. This role will: Coordinate and integrate care: Work alongside the Chronic Disease Management team to pro-actively manage patients with a long-term condition/chronic disease. Act as a central point of contact for patients, their families/carers and practice staff in relation to chronic disease management. Help patients transition seamlessly between primary, secondary and community care services and support patients and their families to navigate through the wider health and care system.
Work with the practice teams to assist patients in accessing self-management education courses, peer support or other interventions that support them in their health and wellbeing and increase their activity levels. Communicate effectively with patients and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Have knowledge of the local health & social care system including referral processes, local pathways etc Work with the Mental Health & Wellbeing team to support patients in accessing local community groups. Recall: Work with the practice teams to ensure that robust recall processes are in place to ensure optimum management of patient conditions.
Monitor and maintain patient recall for all chronic disease patients following up non-attenders. Utilise search functionality within the clinical systems to recall patients. Ensure that all patients have recall dates identified within their clinical record. Work with the wider practice team to ensure that there is sufficient appointment capacity across the practices/PCN.
Work with the wider practice team to identify any barriers for patients in attending their appointments/reviews. Health promotion & pro-active care: Support the practice and PCN staff in raising awareness of health and wellbeing through health events, patient information etc. Utilise searches within the clinical system to identify at risk patients and signpost/refer accordingly. Utilise population health intelligence to proactively identify and work with patients to deliver personalised care.
Screening: Work alongside the practice and PCN staff to improve cancer screening uptake including breast, bowel and cervical. This will include working alongside the Cancer Care Coordinator and Lead Care Coordinator to develop and embed processes to track and follow up screening non-attenders. Support practices to evaluate their screening uptake and engage hard to reach populations to participate in screening, in order to reduce health inequalities. Work with the PCN Member practices to implement a range of activities and implement systems to improve patient uptake of cancer screening programmes including health events, group consultations etc Work collaboratively with local screening teams and the wider support services to increase uptake and follow up non-attenders/responders.
Digital: Utilise healthcare technologies to optimise service delivery, patient access and continuity of care. Support patients to use digital technology to facilitate remote patient monitoring. Administration: Maintain and update patient clinical records in a timely manner to ensure accuracy. Support the Practice Managers across the PCN to monitor and track QOF performance in relation to Chronic Diseases.
Monitor changes to QOF criteria and ensure the practice adapts to new guidelines. Attend MDT meetings as required. Identify areas for improvement within the Chronic Disease Management processes. Provide accurate and timely data to support audit and monitoring, and any data returns as required by the PCN.