Care Coordinator

Job responsibilities

The proactive care team (PACT) is a weekday service and the role involves:

• Performing comprehensive geriatric assessments (CGA) on a cohort of patients with moderate / severe frailty identified with a risk stratification tool, or through other referral routes into PACT (eg, virtual ward discharges).
• Using the CGA template to perform the assessment and document on the clinical reporting system. The assessment will be carried out by the Care coordinator with support and supervision from the wider PACT MDT as needed.
• Working with other members of the PACT MDT to plan and visit patients on a proactive or reactive need, working in patients own homes and care settings.
• Working with the PACT MDT on Enhanced Health in Care homes, anticipatory care planning and supporting personalised care planning.
• Advise patients on maintaining health and refer to allied services when a health promotion need is identified.
• Communicate at all levels within the multidisciplinary team ensuring an effective service is delivered.
• Maintain accurate, contemporaneous healthcare records appropriate to the consultation
• Ensure evidenced-based care is delivered at the highest standards ensuring delivery of high-quality patient care
• Contribute to the weekly PACT MDT, presenting patients for discussion/feedback
• Working with the PACT MDT, PCN practices and wider Community Partnership to identify patients appropriate for the proactive care team model.
• The role will also cover reviews for different cohorts of patients, including learning disabilities and mental health illness reviews and Long-Term Condition Reviews.

This role is constantly developing and new functions are being developed with appropriate training and support.

Working as part of a Team

• Support the flexible delivery and development of the proactive care model within the Five Lane Ends PCN.
• Work in collaboration with other members of the PACT MDT to deliver safe effective service
• Contribute to the wider MDT discussions as part of the feedback process under the proactive care model
• Undertake independent assessments and summarise information to feed back to the MDT

Ability to recognise your own limitations and escalate cases to senior colleagues as appropriate

Managing Self

• Managing your own diary and patient visits
• Participate annually identifying, developing and agreeing your own development plan with your line manager using the Appraisal process.
• Participate in regular supervision.
• Attend all mandatory training.
• Comply with all local and national policies, procedures and protocols.
• Pay regard to materials and equipment.
• Carry out duties with due regard to the Equal Opportunity Policy.
• Seek advice and support from your line manager whenever necessary.
• Ability to work independently and manage workload supported by PACT MDT member

Staff Supervision and Support

• Recognise the need for and provide on-site clinical learning opportunities for junior colleagues, care home staff etc.

Financial Responsibility

No financial responsibility.

Safeguarding

All staff members have a duty to report any concerns they have about the safety or well being of adult service users, members of their families, including children. Employees should be aware of their roles & responsibilities to both prevent and respond appropriately to abuse. They should undertake the safeguarding training required for their particular role.

Infection Control

All clinical and non-clinical staff are responsible for infection control.

This requires you to:

• Maintain infection prevention and control procedures and policies for yourself and others.
• Be familiar with and comply with current infection prevention and control, guidelines, policies and procedures.
• Raise matters of non-compliance with your manager.
• Attend infection prevention and control mandatory training as dictated by your manager.
• Be appraised in relation to infection prevention and control.

Risk Management

All staff need a basic working knowledge of risk management. They all have a responsibility to identify and report risks, hazards, incidents, accidents and near misses promptly, in accordance with Policy. All staff must be familiar with emergency procedures, risk management systems and incident management in their workplace.

Health and Safety

All employees have a responsibility under the Health and Safety at Work Etc Act 1974 for their own health, safety and welfare and to ensure that the agreed safety ...