PCN Frailty Care Coordinator / HCA

Job description

Job responsibilities

As a member of the Armley Primary Care Network (PCN) Frailty Team, the Frailty Care Coordinator/HCA (FCC/HCA) will assist with the delivery of national and local agenda for care of frail patients within their own homes, to enable them to maintain their independence in a safe environment.

They will work alongside, and under the supervision of, registered practitioners to carry out a range of healthcare activities and duties. This work will usually be undertaken in the patients home; however, specific PCN clinics may also require support.

The role includes undertaking delegated clinical tasks and procedures such as phlebotomy, BP recordings, diabetic reviews, foot checks, stroke and kidney disease reviews in the patients home or at one of our 3 GP surgeries.

Working strictly in accordance with specific guidelines and agreed protocols, the FCC/HCA will assist with the ongoing support of patients, families and carers in a professional manner - using resources economically and efficiently.

In line with PCN policy, the FCC/HCA will update patient records using both EMIS and SystmOne, ensuring entries are accurate, relevant, and timely and that they appropriately communicate the care provided.

The FCC/HCA will participate in multidisciplinary and case management meetings, where appropriate, and develop and maintain effective working relationships with health and social care colleagues and other agencies to ensure that frail and complex patients and those with long term conditions receive a consistent, integrated response to all contacts/referrals.

Duties will be undertaken in an autonomous manner with advice from the practice care teams and GPs as appropriate.

The FCC/HCA will understand and follow procedures and policies on information governance, with strict adherence to protocols regarding the sharing of personal and confidential information between different organisations/individuals. Appropriate competency-based training and all mandatory training will need to be completed.

Main Job Responsibilities

Holistically support patients with mild to severe frailty within the community

Undertake frailty reviews of housebound patients for PCN practice sites via home visit, or occasionally via telephone

Review patient needs and help them access the services and the support they require to understand and manage their own health and wellbeing

Refer patients to services within the area that are most appropriate for them

Conduct low level clinical screening such as dementia screening, blood pressure checks and venepuncture as directed by the lead health professional. (Where relevant training has been received)

Carry out low level falls assessment/screening and provide advice and information on falls prevention, including referral for equipment where necessary.

Assist in the formulation and review of care plans to ensure all care is reflecting the patients needs and wishes

Visit housebound patients at the request of PCN practices for Healthcare Assistant-appropriate tasks whilst ensuring these do not detract from core frailty work

Ensure patient records are updated appropriately and consultations recorded using the appropriate template

Liaise with each practice to maintain frailty registers

Liaise with each practice to prioritise visits

Work within the scope of HCA practice

Identify social isolation and loneliness, being proactive in signposting to relevant resources to empower patients to remain active and engaged within their communities

Identify and recognise deterioration in an individuals health and act promptly to refer to relevant health professional to minimise risk or where appropriate, avoid hospital admission

Assist practices in the achievement of targets related to frail and housebound patients

Develop and maintain knowledge and relationships with our practices and local services

Work with local statutory, voluntary and independent organisations to ensure referrals are made appropriately and maximise the availability of local resources.

Take all reasonable precautions to ensure the health and safety of service users and self, understanding and following risk assessments as instructed. To maintain close links with other services in line with Safeguarding procedures and make other appropriate interventions and escalation.

Ensure that GPs, practice nurses, practice pharmacists and other members of the primary care team understand the FCC/HCA role, and which patients may particularly benefit from their input

Work with the Armley PCN and its leadership team to develop and evaluate the effectiveness of this role.

Core Responsibilities:

Frailty reviews for patients within Armley PCN who are house dependent

Assisting each practice to maintain up to date frailty registers

Help to raise awareness of health and wellbeing and how it can be promoted

Assisting with the collection and collation of data on needs related to health and wellbeing

Additional Responsibilities:

On occasion, not as a matter of course, for practices within the PCN:

Phlebotomy

Blood pressure monitoring

Chaperoning duties

Sterilising, cleansing and maintenance of surgical equipment

Assisting in the assessment and surveillance of patients health and wellbeing

Knowledge, Training and Experience:

Minimum NVQ level 3 or equivalent experience in a health and/or social care setting

Evidence of continual professional development

Experience in healthcare provision to a vulnerable group of patients

Specific interest in supporting frail and elderly patients

Experience of Primary Care or other organisations supporting a wide range of individuals.

Knowledge of health care service delivery, public health delivery or community engagement.

Knowledge and understanding of the complexities of General Practice provision.

Completed a two day PCI accredited care co-ordination training course or be willing to complete.

Other:

Maintain the highest standards of conduct and integrity within organisation adhering to relevant Codes of Conduct and the NHS Constitution

Be aware of and adhere to the provisions of the Health and Safety at Work Act and ensure own safety and the safety of colleagues and patients

Participate in our appraisal system, matching organisational aims with individual objectives

Comply with all organisational and statutory requirements

Undertake all mandatory training required for the role

Be aware of individual responsibilities under the Equal Opportunities and Diversity in Employment Policy and adhere to the provisions of the policy

Work flexibly as required by the PCN, including working at different GP Practices or community locations in the local area.

This job description is not meant to be exhaustive. It describes the main duties and responsibilities of the post. Staff are expected to undertake any other duties commensurate with the FCC/HCA grade as agreed with their line manager.

Person Specification

Qualifications

Essential

• Educated to GCSE or equivalent (GCSE Maths & English C or above)
• NVQ level 3 or equivalent experience in a health and/or social care setting
• Evidence of continual professional development
• Full UK Driving Licence

Desirable

• Qualified in Phlebotomy

Knowledge and Skills

Essential

• Understanding of personalised care and the comprehensive model of personalised care
• Understanding of the wider determinants of health
• Promotes diversity and equality and leads by example
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Knowledge of how the NHS works, including primary care and PCNs
• Knowledge of and ability to work to policies and procedures including confidentiality, safeguarding and health and safety
• Ability to recognise/work within limits of competence, seeking advice if needed
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social
• Ability to record accurate clinical notes
• Clear, polite telephone manner
• Good interpersonal skills
• Ability to follow clinical policy and procedure

Desirable

• EMIS and SystmOne user skills

Experience

Essential

• Experience of working directly in a healthcare assistant or care co-ordinator role, or within adult health and social care, learning support or public health / health improvement
• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience of working within multi - professional team environments
• Experience of supporting people, their families and carers in a related role
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Desirable

• Experience or training in personalised care and support planning
• Experience of data collection and using tools to measure the impact of services

Personal Qualities

Essential

• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders
• Ability to identify risk and assess / manage risk when working with individuals
• Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care co-ordinator role
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• Ability to demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
• Demonstrable commitment to professional and personal development
• Completed a two day PCI accredited care co-ordination training course or be willing to complete one.
• Proficient in MS Office and web-based services

Desirable

• Ability to provide motivational coaching to support behaviour change

Other

Essential

• Meets a Disclosure and Barring Service (DBS) reference standards and criminal record checks
• Access to own transport and ability to travel across the PCN on a regular basis

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

Dr G A Lees & Partners

Address

Thornton Medical Centre

15 Green Lane

Leeds

LS12 1JE

Employer's website

https://www.armleymedicalpractice.co.uk/ (Opens in a new tab)