Patient Care and Case Management Act as a central point of contact for patients with complex health and care needs, including long term conditions and mental health issues. Undertake holistic assessments, identifying medical, psychological, and social support requirements. Develop and maintain personalised care and support plans in collaboration with patients, families, and clinical teams. Monitor patients progress, reviewing care plans regularly, and adapting support as needs change.
Support patients to self-manage their conditions where possible, promoting independence and wellbeing. Care Coordination Liaise with GPs, practice nurses, mental health services, community teams, social care, and voluntary sector organisations to ensure integrated care delivery. Proactively identify patients at high risk of hospital admission or deterioration and coordinate appropriate interventions. Facilitate smooth transitions of care, such as hospital discharge planning and onward referrals.
Actively signpost patients to the correct healthcare professional. Ensure that patients have timely access to mental health support, signposting and escalating as necessary. Assist patients to access self-management education courses, peer support or interventions that support them in their health and well-being. Where appropriate, to assist patients to access personal health budgets.
Where appropriate, to support people to access appropriate benefits where eligible as well as taking up employment and training. Provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working closely with social prescribing link workers, occupation therapists and other primary care professionals. Attend and participate in the delivery of multi-disciplinary teams MDT within PCNs. Where appropriate, to support people to access appropriate benefits where eligible as well as taking up employment and training.
Provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working closely with social prescribing link workers, occupation therapists and other primary care professionals. Communication and Collaboration Work as part of a multidisciplinary team, contributing to regular case reviews and clinical meetings. Build strong relationships with community and voluntary sector partners to enhance patient support networks. Advocate for patients, ensuring their voice is heard and their preferences are respected.
Provide information, advice, and guidance to patients and carers in a clear and accessible way. Service Development and Quality Contribute to audits, data collection, and evaluation of the service, identifying areas for improvement. Keep accurate, timely, and up to date records in line with local policies and information governance standards. Generic Responsibilities Share best practice across the PCN.
Be responsible for the day-to-day planning of personal workloads. Follow departmental policies, procedures and guidelines. Develop yourself and the role through participation in training and service redesign activities. Contribute to a patient safety culture through reporting and investigation of incidents and undertaking proactive measures to improve patient safety.
Maintain accurate clinical records of all patient consultations and related work. Review the latest guidance ensuring the practice conforms to regulations eg CQC etc. Support in the delivery of enhanced services and other service requirements on behalf of the PCN. Participate in the management of patient complaints when requested to do so and participate in the identification of any necessary learning brought about through clinical incidents and near-miss events.
Undertake all mandatory training and induction programmes. Contribute to and embrace the spectrum of clinical governance. Attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed.
Contribute to supporting public health campaigns e.g. flu Support delivery of QOF, incentive schemes, QIPP and other quality or cost effectiveness initiatives. Perform other general tasks as assigned. Maintain professional knowledge, attending training and development as required.