This post is offered to support existing Care Coordinator colleagues in St Peters Hill Surgery in Grantham to increase capacity to support people in their own homes and within care home settings.
The role will be employed within K2 Healthcare and based within the Grantham Neighbourhood Hub.
Main duties of the job
The role of the Practice Care Co-ordinator is to support both the practice staff and members of the Neighbourhood Team to identify and support people to reduce the risk of unplanned hospital admissions and to effectively support those individuals in the community.
To work dedicated hours to focus on proactively case managing people and being the preferred point of contact for the patient and Neighbourhood Team to achieve the following objectives:
* To be a pro-active member of the Integrated Neighbourhood Team and Southwest Primary Care Networks.
* To pro-actively engage with people deemed to be at risk of hospital admission or health deterioration.
* To proactively engage with frequent fliers those attending A&E and utilising OOH services.
* To pro-actively engage with HomeFirst Teams to reduce length of stay in acute hospital settings.
* To pro-actively engage with people living in care home settings.
* To be the key contact within the GP Practice environment.
About us
K2 Healthcare is a GP federation constituted of 16 member GP Practices in South West Lincolnshire with two Primary Care Networks and supporting a population of 133,000 people.
K2 works together to share resources and expertise that enable practices to provide shared services and business systems to provide the best possible care for our population, ensure sustainability, growth and value for GP practices and system partners within available resources.
The Better Lives Lincolnshire Integrated Care System sees us working in a provider collaborative with the Primary Care Network Alliance, Secondary Care, Community Health, Mental Health, Social Care as well as Local Authorities, and the Community and Voluntary Sector.
How we do it is as important as what we do and relationships with our partners is at the core of everything we do.
Neighbourhood Working describes an integrated approach to managing patients, through a blended workforce that encompasses both health and social care; to include acute, voluntary and community sectors where barriers to working are negated, the health and wellbeing needs of the individual are at the centre of decision-making, care is proactive and not reactive, and services are provided in a timely manner.
Job responsibilities
ROLE SUMMARY
Neighbourhood Working is a new way of strengthening and redesigning community services for a local population. It empowers people and communities to take an active role in their health and wellbeing, with greater choice and control over the care they need. It also supports the improvement, integration, and personalisation of services in Lincolnshire.
Core Neighbourhood Working Principles
* Having a different conversation
* Enabling self-care and peer support
* Recognising what's important to me
* Assessing immediate needs and addressing barriers to improve quality of life
To liaise with the registered GP and other practice-based staff in addition to all other providers and services utilising, where appropriate, a multi-disciplinary approach.
To implement and review individual care plans, self-management plans in liaison with the GP practice team. To include advanced care plans, Respect documents, personalised care and support plans.
Plan and monitor those on GP caseloads and directed by the practice team or identified by the wider Neighbourhood Team at risk of deterioration.
Provide enhanced support to Nursing and Residential homes with a focus on strengthening relationships and improving access through information sharing, education, and advice.
To ensure all people in Nursing and Residential homes have care plans including advanced care plans, Respect documents, personalised care, and support plans and to provide a holistic review of all people in these homes with updates of their plans.
KEY RESPONSIBILITIES
* Act as a point of contact between the GP Practice Team, Neighbourhood Team, people and their carers.
* Develop and maintain a detailed knowledge of local services to enable supported signposting of people with identified need, sharing information with the Neighbourhood Team/Primary Care Network.
* Liaise with GPs and practice teams to identify people who are elderly, frail or who have long-term health needs and support.
* Support the early identification of those with life-limiting conditions including palliative and end-of-life symptoms to support a good end-of-life experience.
* Liaise with primary, secondary, and specialist care services as required.
* Work with Neighbourhood Team colleagues to help identify people at risk of loss of independence or hospital admission due to inadequate social support.
* Provide signposting to services to maintain independence and improve health and well-being.
* Visit people in community, home, or care home settings to assess and discuss their care needs involving carers as appropriate.
* Implement personal care plans, ensuring preventative actions support appropriate service use.
* Communicate the care plan to the GP and other team members and upload to relevant records.
* Ensure timely help for identified people and facilitate joined-up services by liaising with relevant team members.
* Encourage patients to adopt effective self-management and self-help seeking approaches to reduce unnecessary hospital admissions.
* Liaise with other agencies for timely and appropriate engagement.
* Support access to community care and carers assessments.
* Advise on personal healthcare budgets when allocated.
* Identify unpaid carers and direct them to support services.
* Recognize urgent needs or a step-up in care and alert relevant team members, highlighting safety concerns.
* Follow up on hospital and inpatient service communications regarding changes in patient condition.
* Manage cases following hospital admissions through visits or calls.
* Participate in multidisciplinary meetings to discuss managed individuals and others needing review.
* Attend Neighbourhood Team MDT meetings and share updates.
* Maintain accurate records using GP systems and other IM&T systems, including running regular patient searches and supporting KPI reporting.
* Support the development of this role in collaboration with K2 Federation Southwest Primary Care Networks and other agencies.
#J-18808-Ljbffr