Job responsibilities
Work as an integral member of the team caring for patients with complex health and care
needs, including long term conditions and mental health issues.
Undertake
holistic assessments, identifying medical, psychological, and social support
requirements.
Develop
and maintain personalised care and support plans in collaboration with clinical teams, patients and families.
Monitor
patients progress, reviewing care plans regularly, and adapting support as
needs change.
Support
patients to self-manage their conditions where possible, promoting
independence and wellbeing.
Care Coordination
Liaise
with GPs, practice nurses, mental health services, community teams, social
care, and voluntary sector organisations to ensure integrated care delivery.
Proactively
identify patients at high risk of hospital admission or deterioration and
coordinate appropriate interventions.
Facilitate
smooth transitions of care, such as hospital discharge planning and onward
referrals.
Actively
signpost patients to the correct healthcare professional.
Ensure
that patients have timely access to mental health support, signposting and
escalating as necessary.
Assist
patients to access self-management education courses, peer support or
interventions that support them in their health and well-being.
Where
appropriate, to assist patients to access personal health budgets.
Where
appropriate, to support people to access appropriate benefits where eligible
as well as taking up employment and training.
Provide
coordination and navigation of patients, and where appropriate their carers,
across health and social care services, where appropriate working closely
with social prescribing link workers, occupation therapists and other primary
care professionals.
Attend
and participate in the delivery of multi-disciplinary teams MDT within
PCNs.
Where
appropriate, to support people to access appropriate benefits where eligible
as well as taking up employment and training.
Provide
coordination and navigation of patients, and where appropriate their carers,
across health and social care services, where appropriate working closely
with social prescribing link workers, occupation therapists and other primary
care professionals.
Communication and
Collaboration
Work
as part of a multidisciplinary team, contributing to regular case reviews and
clinical meetings.
Build
strong relationships with community and voluntary sector partners to enhance
patient support networks.
Advocate
for patients, ensuring their voice is heard and their preferences are
respected.
Provide
information, advice, and guidance to patients and carers in a clear and
accessible way.
Service Development
and Quality
Contribute
to audits, data collection, and evaluation of the service, identifying areas
for improvement.
Keep
accurate, timely, and up to date records in line with local policies and
information governance standards.
Generic Responsibilities
Share
best practice across the PCN.
Be
responsible for the day-to-day planning of personal workloads.
Follow
departmental policies, procedures and guidelines.
Develop
yourself and the role through participation in training and service redesign
activities.
Contribute
to a patient safety culture through reporting and investigation of incidents
and undertaking proactive measures to improve patient safety.
Maintain
accurate clinical records of all patient consultations and related work.
Review
the latest guidance ensuring the practice conforms to regulations eg CQC etc.
Support
in the delivery of enhanced services and other service requirements on behalf
of the PCN.
Participate
in the management of patient complaints when requested to do so and participate
in the identification of any necessary learning brought about through clinical
incidents and near-miss events.
Undertake
all mandatory training and induction programmes.
Contribute
to and embrace the spectrum of clinical governance.
Attend
a formal appraisal with their manager at least every 12 months. Once a performance/training objective has
been set, progress will be reviewed on a regular basis so that new objectives
can be agreed.
Contribute
to supporting public health campaigns e.g. flu
Support
delivery of QOF, incentive schemes, QIPP and other quality or cost
effectiveness initiatives.
Perform
other general tasks as assigned.
Maintain professional knowledge, attending
training and development as required.
