We arelooking for a Frailty Co-Ordinator's to join our Multi Disciplinary Team to helpus to work towards our responsibilities within the PCN Directed EnhancedServices (DES) Contract.
CareCoordinators play an important role within a PCN to proactively identify and workwith frail and elderly people, to provide coordination and navigation of care and support acrosshealth and care services.
We areparticularly looking for our Frailty Coordinator to focus on our Frailty Admission Avoidance Scheme, Health Inequalities and Social Prescribing, working with theexisting teams and Clinical leads to achieve positive change for our patients.
Thesuccessful candidate will be expected to complete training appropriate to therole, including a 2-day Care Coordinator or Health Coaching Course.
If you would like to know more about the role, we would very muchwelcome a discussion with you please contact Claire Knight, Business Manager atClaire.Knight2@staffs.nhs.uk.
Main duties of the job
We arelooking for someone who is empathetic, organised with great interpersonalskills who will be committed to delivering the highest quality of service toour patients.
If you have whatit takes and have the experience as follows, we would like to hear from you:
Experienceof working with healthcare professionals and or previous experience in the NHSor social care or relevant field, including unpaid work.
Experienceof supporting people, their families and carers in a related role, includingunpaid work.
Experienceof data collection and providing monitoring information to assess the impact ofservices.
Experienceof partnership/collaborative working and of building relationships across avariety of organisations.
Workingin a multi-disciplinary setting where influence and negotiation is required.
Advancedexperience of using word, excel and PowerPoint including ability to use wordprocessing skills, emails and the internet to create simple plans and reports.
Creativeproblem solver and willing to search for hard-to-find information.
Accessto own transport and ability to travel across the locality on a regular basis
The role will involve working across any of our 5 local practicesand occasional travel further afield.
About us
Leek andBiddulph PCN are a group of five GP practices working together to focus onlocal patient care. We are amulti-disciplinary team, covering Leek and Biddulph, responsible for thehealthcare of just over 50,000 patients. We are led by Dr Neil Briscoe our PCNClinical Director and a supportive management team.
We are a veryforward thinking and innovative PCN who became the first PCN inNorth Staffordshire to convert to a Limited Company. We utilise to the full, the skills andexperience of the team members it includes Care Co-Ordinators, Clinical Pharmacists, PharmacyTechnicians, Occupational Therapists, Physiotherapists, SocialPrescribers and Mental Health Practitioners. We have a flexible approach toworking patterns and generous terms and conditions including the NHS Pension.
We aresupportive of professional development and pride ourselves on developing newroles in a collaborative and friendly environment
Job responsibilities
Key Responsibilities
The role will be to provide holistic assessments under the Facilitation of Admission Avoidance Scheme. The assessments will be face to face and given the patient cohort will predominantly be completed in the patients homes or in clinic. The post holder will be expected to:
* Develop, implement and review personalised care plans that meet physical, emotional and social needs of frail older adults
* Identify early signs of deterioration and implement proactive interventions to avoid hospital admissions where appropriate
* Promote self-management and independence in patients with long term conditions
* Support in advanced care planning conversations where appropriate
* Co-ordinate access to additional services, team members and care packages as appropriate
* Work with the multi-disciplinary team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.
* Provide these cohorts of people signposting to identified services in order to maintain their independence and improve their health and wellbeing.
* Visit patients in community, home or clinic settings to assess and discuss their care needs involving carers as appropriate.
* Maintain accurate and up to date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e. entering notes onto EMIS using agreed SNOMED codes.
* To run regular patient searches using EMIS in order to have an up to date record of progress of achievement of Key Performance Indicators.
* Support the PCN in providing KPI reports for submission as requested.
* Ensure all patients under the FAAS have a fully completed care plan, liaising with patients and clinicians where appropriate.
Person Specification
Experience
* Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field, including unpaid work
* Experience of supporting people, their families and carers in a related role, including unpaid work
* Experience in use of databases
* Experience of data collection and providing monitoring information to assess the impact of services
* Experience of partnership/collaborative working and of building relationships across a variety of organisations
* Working in a multi-disciplinary setting where influence and negotiation is required
* Knowledge/familiarity with medical terminology
* Vulnerable adults awareness
* Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports
* Creative problem solver and willing to search for hard-to-find information
* Access to own transport and ability to travel across the locality on a regular basis
* Continued commitment to improve skills and ability in new areas of work
* Experience of care of the elderly.
* Experience of working as a Health Care Assistant.
* Experience of working with or in general practice.
* Knowledge of general practice clinical systems, such as, EMIS.
Qualifications
* NVQ 2 or above in Health and Social Care or Diploma/ HNC level in a relevant field, or relevant experience
* Demonstrable commitment to professional and Personal Development
* Training as set out by the Personalised Care Institute, or willingness to complete.
* Knowledge of primary care IT Systems
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.
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