Job responsibilities
Hours: 15 hours per week. Your normal working hours will be Monday,
Tuesday and Wednesday at the Tutbury Health Centre; 5 hours per day during core working
hours.
Responsible
to: The
IM&T Manager
Accountable to: Practice Manager and Partners
General
description of the post:
The Enhanced Health in Care Homes model moves us away from reactive care to a
proactive model of care, this role is pivotal in making this happen.
To act as the central point of access for all care homes to support the
delivery of the Enhanced Health in Care Homes element of the Primary Care
Network (PCN) Direct Enhanced Service.
Duties:
To develop and refresh as required a personalised care and support plan for
every resident a standard template will be developed. Within 7 working days
of admission to the home and within 7 working days of readmission following a
hospital episode. This is to be done in conjunction with the patient, family
and or carer and MDT members. Work with the Practices to ensure that all
relevant information is held within the patients medical record when
transferring to a new practice. List of up to date medication, ESCAs, summary
print out is requested from their previous practice if required
Draw on any existing assessments that have been made.
Use a directory of services
(this will be complied for you but it is expected that in time you will forge
links with other external provision to help enhance the care and support
available to care homes) to navigate the right care to the right home as and
when this is required. This
active engagement with external providers will include the
voluntary sector and Social Prescribing link workers.
To be the central point of contact for all care homes and
ensure that each care home has access to a weekly check in home round
facility and prioritise residents for review according to identified need based
on MDT clinical judgement and care home advice.
To identify and or engage in locally organised shared
learning opportunities as appropriate and as capacity allows.
Actively encourage an excellent working relationship with
the care home and support them to self-manage by disseminating educational
material, advice and guidance as prepared by MDT members when and where
appropriate.
To ensure that action points arising from MDT meetings are
followed up
To support the patients discharge from hospital and
transfers of care between settings giving due regard to NICE Guideline 27 Relates
to referrals only
Assist with the collection of data required for the PCN
EHCH DES
Implement and co-ordinate advanced care plans on annual
bases and when notified of a new patient.
Work with the home (and MDT) in coordinating their flu
immunisation campaign.
Where someone is identified as likely to die in next few
days or hours, to ensure everyone who needs to be aware is. Liaise with
dispensary and GPs to ensure anticipatory drugs, DNAR etc all arranged. Liaise
with St Giles as appropriate. The patients care plan is reviewed and
treatment escalation plan in place. Family have been informed and DNAR etc
discussed. If a treatment plan surrounding their death is in place it is
followed where possible, through collaboration with the home and other in the MDT
where necessary. Following a death, ensure that the relevant parties have been
informed. Bereavement support is available for the families (and care workers)
Ensure ADASTRA form is uploaded in a timely manner.
Aware of when SMRs need doing, add them to the MDT meetings
to ensure all relevant parties review medications of the patient.
If a falls prevention plan is in place, ensure it is
reviewed as required, at least annually. Ensure it is on the agenda for the MDT
meetings.
Identify who needs a review, of what, when. Make sure that
the relevant parties are aware, follow it up to make sure it has been actioned.
Co-ordinate hospital discharges i.e. onward referrals,
(where a patient has had a fall, referral to falls team) medication changes,
DNARs etc
Confidentiality:
All
patient information that you come into contact with must be dealt with in the
strictest of confidence. Any breach in
confidence can lead to instant dismissal:-
In the
course of seeking treatment, patients entrust us with, or allow us to gather,
sensitive information in relation to their health and other matters. They do so in confidence and have the right
to expect that staff will respect their privacy and act appropriately
In the performance of the duties outlined in this Job
Description, the post-holder may have access to confidential information
relating to patients and their carers, Practice staff and other healthcare
workers. They may also have access to
information relating to the Practice as a business organisation. All such
information from any source is to be regarded as strictly confidential
Information relating to patients, carers, colleagues, other
healthcare workers or the business of the Practice may only be divulged to
authorised persons in accordance with the Practice policies and procedures
relating to confidentiality and the protection of personal and sensitive data.
Health & Safety:
The post-holder will assist in promoting and maintaining their
own and others health, safety and
security as defined in the Practice Health & Safety Policy, to include:
Using personal security systems within the workplace according
to Practice guidelines
Identifying the risks involved in work activities and
undertaking such activities in a way that manages those risks
Making effective use of training to update knowledge and skill
Safeguarding:
All
employees are required to act in such a way that at all times safeguards the
health and wellbeing of children and vulnerable adults. Familiarisation with
and adherence to Safeguarding policies is an essential requirement of all
employees as is participation in related mandatory/statutory training. For
further information regarding these policies please look at the T:Drive folder
under Safeguarding, or the Staffordshire Safeguarding Childrens Boards website.
We
operate a No Smoking Policy.
