Job Purpose To focus on the identification and management of vulnerable patients (initially those with moderate and severe frailty and subsequently those living with long term conditions). This refocus is fundamental to the delivery of the Integrated Care System (ICS) Frailty Programme. To work in alignment with the delivery of the ICS Integrated Care Strategy and NHS Joint Forward Plan addressing the specific needs of an ageing population and recognizing the economic and quality of life impacts of prioritising frailty management Dimensions The post holder will work closely with Primary Networks (PCNs) acting as the named point of contact for information and a guide to processes for health and social care professionals within the PCN The post holder will be accessible to patients members of the PCN via a dedicated telephone line between the hours of 8am and 6pm Key Responsibilities Undertake daily identification of frailty and long-term condition workflows on E-Healthscope and decide the best course of action based on agreed Standard Operating Procedures (SOPs) and advice from clinicians/other key leads. Proactively contact patients to complete the CFS and provide advice and refer to teams/services/local assets (where appropriate) Undertake a holistic assessment/goal setting to ensure an advanced care plan is in place and agreed e.g.
All About Me Provide information to members of the PCN to aid communication Complete relevant referral documentation and chase referrals as required and navigate and coordinate services to meet individuals needs across the PCN. Access systems utilised across the ICS to support case analysis this includes but not limited to, Social Care, Mental Health and General Practice Work closely with the integrated neighbourhood team for access to community-based activities Neighbourhood team MDT Meetings Be responsible for facilitating regular (monthly as a minimum) multidisciplinary team meetings for each practice within the nominated PCN Be responsible for arranging, attending and minuting the neighbourhood (MDT) meeting and compiling agendas and undertaking associated administrative work and initiating referrals within agreed format / process where appropriate following the discussions. All cases on the list will be reviewed and decisions logged on the risk of admissions register Integrated Neighbourhood Team Meetings (INT) Be responsible for co-ordinating INT meetings across the PCNs Compile a list of patients to discussed in line with the standard operating procedure document, initiate any onward referrals Data management To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the (MDT) team and providing information to any member of the neighbourhood team to ease processes and communication in agreement with data protection protocol To be responsible for recording, reporting and producing evaluation reports which will include evaluation detailing effectiveness outcomes of new roles. To receive, breakdown and co-ordinate data and produce spread sheets for analysis (which shall include identification of referral trends and geographical spread of referrals and interventions to support the delivery of care within the PCN) Support and undertake service monitoring, evaluation and documenting outcomes to ensure consistent delivery of high quality, effective and cost-effective services