Work with people, their families, and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. 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. To be a central point of contact for our Care Home and organise appointment, prescription and care requests appropriately. Including referrals to the community teams.
Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined up service and the most appropriate support. Work collaboratively with GPs and other primary care professionals within the practice to proactively identify and manage a caseload, and where appropriate, refer back to other health professionals within the practice. Support the coordination and delivery of multidisciplinary teams with the practice. Including arranging MDT and GSF meetings where appropriate Raise awareness of how to identify patients who may benefit from shared decision making and support practice staff and patients to be more prepared to have shared decision making conversations.
Explore and assist people to access a personal health budget where appropriate. Identify unpaid carers and help them access services to support them. Conduct follow-ups on communications from out of hospital and in-patient services. Maintain records of referrals and interventions to enable monitoring and evaluation of the Service Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances.