Key Responsibilities Coordinate and integrate care for residents of care homes in line with the Enhanced Health in Care Homes Framework Work with the lead of the care home team, the care home physician assistant, GPs and other primary care professionals within the PCN to identify and manage a caseload of care home residents, and where required and as appropriate, refer people back to other health professionals within the PCN. Organise and chair multidisciplinary meetings of the care home team which includes GPs, care home staff, community nurses, social workers, pharmacists and other health care professionals as needed Ensure that all discussions and decisions from the care home multidisciplinary team (MDT) meetings are accurately documented, and that agreed actions are followed up and completed in a timely manner. Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care, using tools to understand peoples level of knowledge, confidence in skills in managing their own health Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances Demonstrate a thorough understanding of the Enhanced Health in Care Homes (EHCH) Framework, actively implementing its principles and continuously identifying opportunities to improve the service in line with its standards and evolving best practices Enable access to personalised care and support Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them Provide coordination and navigation for residents and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals Provide residents and their families with high-quality information to aid in making informed choices about their care. Raise awareness within the PCN of shared decision-making and decision support tools Miscellaneous Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators to enhance the coordination of care for the residents Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities Contribute to the wider aims and objectives of the PCN to improve and support primary care Aid implementation of the seasonal vaccination programmes such as COVID-19 and influenza Professional Development Work with your line manager to undertake continual personal and professional development taking an active part in reviewing and developing the role and responsibilities Adhere to organisations policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety Health and Safety/Risk Management Must always comply with the Health and Safety policies, in particular following safe working procedures and reporting incidents using the organisations Incident Reporting Systems Comply with the Data Protection Act and the Access to Health Records Act