PCN Frailty Co-ordinator
Job Description
Job summary
We are looking for a Frailty Co-Ordinator's to join our Multi Disciplinary Team to help us to work towards our responsibilities within the PCN Directed Enhanced Services (DES) Contract.
Care Coordinators play an important role within a PCN to proactively identify and work with frail and elderly people, to provide coordination and navigation of care and support across health and care services.
We are particularly looking for our Frailty Coordinator to focus on our Frailty Admission Avoidance Scheme, Health Inequalities and Social Prescribing, working with the existing teams and Clinical leads to achieve positive change for our patients.
The successful candidate will be expected to complete training appropriate to the role, including a 2-day Care Coordinator or Health Coaching Course.
If you would like to know more about the role, we would very much welcome a discussion with you please contact Claire Knight, Business Manager at [email protected].
Main duties of the job
We are looking for someone who is empathetic, organised with great interpersonal skills who will be committed to delivering the highest quality of service to our patients.
If you have what it takes and have the experience as follows, we would like to hear from you:
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 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.
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
The role will involve working across any of our 5 local practices and occasional travel further afield.
About us
Leek and Biddulph PCN are a group of five GP practices working together to focus on local patient care. We are a multi-disciplinary team, covering Leek and Biddulph, responsible for the healthcare of just over 50,000 patients. We are led by Dr Neil Briscoe our PCN Clinical Director and a supportive management team.
We are a very forward thinking and innovative PCN who became the first PCN in North Staffordshire to convert to a Limited Company. We utilise to the full, the skills and experience of our team members which includes Care Co-Ordinators, Clinical Pharmacists, Pharmacy Technicians, Occupational Therapists, Physiotherapists, Social Prescribers and Mental Health Practitioners. We have a flexible approach to working patterns and generous terms and conditions including the NHS Pension.
We are supportive of professional development and pride ourselves on developing new roles 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
Essential
- 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
Desirable
- 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
Essential
- 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.
Desirable
- 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.
Employer details
Employer name
Leek and Biddulph PCN
Address
Leek & Biddulph PCN
And all Practices within
ST13 6JB
United Kingdom
