Main Duties and Areas of Responsibility: Service Delivery You will build and develop a robust knowledge and understanding of health, social and third sector provision in the Primary Care Network area. Develop good working relationships with fellow Care Co-ordinators and Social Prescribing Link Workers and contribute to the development of the Integrated Care Co-ordination Service for the PCN. Develop strong working relationships with clinical and non-clinical staff in your aligned GP practice and also with other practices within the PCN Develop a partnership working approach with workers from health, social and third sector providers in the PCN area Prepare proactive care plans for vulnerable patients. Build relationships with patients, their families and carers. Carrying out regular visits, telephone consultations and reviews within the community setting and at dedicated venues. Be the patients advocate to the health and social care system. Signpost patients to appropriate services and sources of funding and where appropriate assist in accessing such funding. Communication Attend aligned practice level MDT meetings to discuss patients and coordinate with other care providers as required. Attend team meetings of the PCN Integrated Care Co-ordination Service and report to the PCN Care Co-ordination Team Leader. Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed. Communicate with and support patients who are receiving bad news. Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating. Anticipate barriers to communication and take action to overcome this. Maintain effective communication within the practice environment and with external stakeholders. Delivering a quality service Produce accurate, contemporaneous and complete records of patient contact, consistent with legislation, policies and procedures. Prioritise, organise and manage own workload in a manner that maintains and promotes quality. Assess effectiveness of care delivery through self and peer review, benchmarking, and formal evaluation. Participate in the maintenance of quality governance systems and processes across the organisation and its activities. Utilise the audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required. In partnership with other clinical teams, collaborate on improving the quality of health care responding to local and national policies and initiatives as appropriate. Evaluate patients responses to health care provision and the effectiveness of care. Support and participate in shared learning across the wider organisation. Assess the impact of policy implementation on care delivery Understand and apply legal issues that support the identification of vulnerable and abused adults, and be aware of statutory vulnerable patients health procedures and local guidance. The post holder will comply with the organisations policies and procedures: Collaborative Working Relationships Understand your own role and scope, work within this scope of practice and identify how this may develop over time. Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working. Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence. Create clear referral mechanisms to meet patient need. Actively work towards developing and maintaining effective working relationships across the PCN. Prioritise own workload and ensure effective time-management strategies are embedded. Work effectively with others to clearly define values, direction and policies impacting upon care delivery. Discuss, highlight and work with the team to create opportunities to improve patient care. Liaise with other stakeholders as needed for the collective benefit of patients. Recognise personal limitations and refer to more appropriate colleagues when necessary. Actively work towards developing and maintaining effecting working relationships across the PCN. Foster and maintain strong links with all services across locality. Explore the potential for collaborative working and take opportunities to initiate and sustain such relationships. Managing information Use technology and appropriate software as an aid to management in planning, implementation and monitoring of care, presenting and communicating information. Ensure that patient data is kept confidential at all times and is shared on a need to know basis only. Understand responsibility of self and others regarding the Freedom of Information Act Collate, analyse and present data and information to the team. Education, Training and Development Understand and demonstrate the characteristics of a role model to members in the team and/or service. Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments (e.g. courses and conferences). Assess own learning needs and undertake learning as appropriate. Demonstrate self-development through continuous professional development activity; working alongside colleagues to identify areas to develop. Enrol into review and appraisal systems within the network. Equality and Diversity You must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc. You must demonstrate respect for patient confidentiality at all times You should respect patient confidentiality at all times and not divulge patient information unless sanctioned by the requirements of the role. Special Working Conditions You will be required to travel independently between practice sites (where applicable), patients homes, community settings and to attend meetings with other agencies. Ability to drive and access to a vehicle will be required. Job Description Agreement This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to take into account development within the network. All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the network. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post-holder. Health and Safety/Risk Management You must comply at all times with the Practices Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System. You must comply with the Data Protection Act (2018) and the Access to Health Records Act (1990).