Job Description
Mid Kent PCN Care Home/Frailty Care Coordinator
Hours of work: 22.5
Contract: Permanent
Responsible to: Mid Kent PCN Manager
Based: Mid Kent PCN (Ashford)
2. JOB SUMMARY
The post holder will be part of the Mid Kent Primary Care Network (PCN) Multi-Disciplinary team (MDT) working alongside healthcare professionals and non-clinical staff to provide a person-centred, proactive approach to healthcare for people with frailty and/or who reside in Care Homes.
The post holder will play an important role within the PCN to proactively identify and work with people, including the frail/elderly, those with long-term conditions and/or living in care homes, to provide coordination and navigation of care and support across health and care services.
The post holder will work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. The post holder will review patients’ needs and help them and/or their carers to access the services and support they require to understand and manage their own health and wellbeing, referring to other professionals where appropriate.
Please note that the role of a care coordinator is not a clinical role.
3. DUTIES AND RESPONSIBILITIES OF THE POST
1. Improve continuity of care by acting as a point of contact for residents, families and professionals who visit care homes, such as MDT members and in-reach specialists.
2. Support the MDT with the weekly virtual home round through identification of people in need of review, or collation of information on people requiring an MDT review in addition to providing coordination and administrative support to the MDT.
3. Attend bi-weekly care home MDT meetings, take comprehensive minutes accurately and document actions and outcomes appropriately on patients’ clinical records.
4. Regularly liaise with local Care Homes to gather patient information ahead of MDT meetings, to include any safeguarding concerns, emergencies, hospital admissions and outcomes from these events or any new admissions or discharges.
5. Be first point of contact for Care Home Managers to report any concerns or ask for support from PCN practices.
6. Provide coordination and navigation for people and their carers across health and care services, working closely with primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
7. Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present to the MDT as required.
8. Liaise with service providers and clinicians to identify “frequent flyers” and new service users utilising risk stratification tools provided and present to the MDT as required.
9. Support completion of new referrals by checking criteria and where this is met, direct referral to the MDT.
10. Work sensitively 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.
11. Help patients/carers 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.
12. Assist patients/carers to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing the healthcare needs of the people they care for.
13. Co-ordinate detailed referrals from Health and Social Care professionals, communicate and answer queries from all disciplines. Organise own day to day activities, plan both straightforward and more complex on-going referrals, together with looking in to the longer term planning of care.
14. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
15. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.
16. Support the development of communication channels between GPs, people and their families and carers and other agencies;
17. Identify unpaid carers and help them access services to support them;
18. Conduct follow-ups on communications from out of hospital and in-patient services;
19. Maintain records of referrals and interventions to enable monitoring and evaluation of the service;
20. Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the person’s circumstances;
21. Manage reporting required and associated within the DES specification for required services;
22. Work with commissioners, integrated locality teams and other agencies to support and further develop the role.
Administration responsibilities:
1. Ensuring accurate coding of care within patients records
2. Taking messages and passing on to relevant team members as appropriate
3. Computer data entry/data allocation and collation, processing and recording information in accordance with practice procedures, keeping accurate and up to date records of contacts.
4. Initiating contact with and responding to requests from patients, other team members and associated healthcare professionals and providers
5. Organise meetings as required
6. Co-ordinating service outcome measures and producing outcome reports for the PCN Board
Analytical and Judgement skills:
1. Participate in risk assessments and determine the appropriate course of action, taking into consideration a range of possible options. Where necessary, ensure that consultation with senior colleagues is undertaken.
2. Have an awareness of their own competencies, knowledge base and experience, and ensure that they practice within this and seek support as required.
Other responsibilities include:
1. Communicate information in a way that makes it relevant and understandable for service users, carers and practice staff, working in line with practice standards and operational policies.
2. Courteously and efficiently receive enquiries, communicate effectively with staff at all levels across internal and external to the organisation, either by telephone, email or receiving visitors in person, in a tactful and sensitive manner, respecting confidentiality at all times.
3. Establish strong working relationships with the PCN teams, secondary care colleagues, GPs and practice teams and work collaboratively with other care coordinators
4. Actively contribute to and develop multi-disciplinary team working processes
5. Plan and be responsible for own workload using own initiative and manage time effectively to deadlines. Support the workload of other members of the team to ensure that care is provided line with PCN and practice standards
6. Ensure that appropriate action is taken in safeguarding adults and children. This will include attending safeguarding meetings and implementing relevant care plans and risk assessments
7. Duties will vary from time to time as may be reasonable within the general character of the post of level of responsibility of the role dependent on current and evolving practice workload and staffing levels.
4. KEY WORKING RELATIONSHIPS
The post holder will deal with the PCN, the wider healthcare community, external organisations and the public. This will include verbal, written and electronic media.
Of particular importance are working relationships with:
* GPs
* Practice managers
* Practice staff
* PCN staff members
* Secondary care colleagues
* Patients and their carers
* Voluntary sector agencies
* Community rehabilitation team
* Urgent community responses team
* Acute care teams
* Community inpatient teams
* Home care agencies
5. WORK SETTING AND REVIEW
* To be sufficiently confident in skills and knowledge to manage own workload efficiently and effectively on a daily basis.
* Follow PCN practice policies and protocols.
* Maintain and update own training relevant to the post and take an active part in the development review of own work suggesting areas for learning and development in the coming year.
* Be focused on solutions and a “can-do” proactive approach.
* Attend regular meetings with Line Manager to agree priorities and overall approach.
6. CONFIDENTIALITY
The post holder must maintain the confidentiality and security of information about patients, staff and Mid Kent PCN business in accordance with practice policies and protocols.
Job Types: Full-time, Permanent
Pay: £12.50 per hour
Expected hours: 22.5 per week
Benefits:
* Company pension
* Employee discount
* On-site parking
Schedule:
* Day shift
* No weekends
Ability to commute/relocate:
* Ashford, Kent: reliably commute or plan to relocate before starting work (required)
Work Location: In person
Application deadline: 25/10/2024
Expected start date: 01/12/2024
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