Job responsibilities
Title: Care Co-ordinator: Frailty
Responsible To: Clinical Team Manager
Main Purpose of the Post: The
aim of the role is to support individuals to manage their health and
wellbeing and continue to live independently in their own homes for as long
as possible.
The
post holder will provide an innovative, integrated service to anyone who has
been identified as frail or at risk of frailty. The role requires a caring, dedicated,
reliable and patient focused individual who enjoys meeting new people.
The
post holder will work both as part of the general practice team, playing a
role in coordinating care and support to individuals. They will manage a
short term caseload supporting the arrangements for appropriate care and
support and ensuring that unplanned, changing needs are addressed and that
individuals are accessing appropriate support.
Duties & Responsibilities of the Post:
Main Duties:
- To visit and support patients at home to assess whether there is
any unmet health or care needs.
- To complete holistic person centred care planning.
- Where unmet needs are identified to complete relevant referrals
- To attend Multidisciplinary Team (MDT) meetings.
- There will be an element of clinical assessment required such as
observations (training will be provided)
It is important to
note that this is a new venture and both the role and the team will develop
and adapt as necessary. Its an exciting venture for both Portsdown Group
Practice and the successful applicants and its success will be created by
everyone who will work within the newly formed team.
Assessment:
Carry out a holistic, person centred
assessment which looks at the health and social
needs of the person, conducted
in partnership with the individual person, their family
and carers. The assessment will be conducted, whenever
possible, in the persons
own home to take account of
environmental factors and to fully understand the
persons functional ability in a
familiar setting.
Carry out agreed specific
assessments including a basic falls risk assessment
Develop and agree care plans and if
necessary reviews for ongoing needs.
Intervention:
Refer and liaise with a range of
statutory and voluntary sector support agencies,
ensuring the person has access
to a wide range of support
Where necessary identify urgent
needs taking relevant action or liaison.
Refer for relevant equipment to
increase the persons independence.
Provide guidance and support to
increase the use of self-care methods.
Conduct clinical screening such as
dementia screening and blood pressure
checks as directed by the lead
health professional. (Where relevant training has been
received)
Carry out falls assessment/screening
and provide advice and information on
falls prevention, including
referral for equipment where necessary.
Monitor and review care plans and
agreed outcomes in partnership with the person
and to evaluate outcomes. This would involve re-negotiating care
plans as and when
required
Act as the key advocate for the
person as and when required
Confidentiality:
As per both Government legislation and Practice Policies ensure that
all confidentiality, data protection and information governance policies and
guidelines are followed and strictly adhered to, reporting any infringements
to the Operations Office immediately.
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, the
practice Health & Safety manual, and the practice Infection Control
policy and published procedures. This will 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 skills
- Using appropriate infection control
procedures, maintaining work areas in a tidy and safe way and free from
hazards
- Actively reporting of health and safety
hazards and infection hazards immediately when recognised
- Keeping own work areas and general / patient
areas generally clean, assisting in the maintenance of general standards
of cleanliness consistent with the scope of the job holders role
- Undertaking periodic infection control
training (minimum annually)
- Reporting potential risks identified
- Demonstrate due regard for safeguarding and
promoting the welfare of children.
- Reporting potential risks identified.
Equality and
Diversity:
The post-holder will support the equality,
diversity and rights of patients, carers and colleagues, to include:
- Acting in a way that recognizes the importance of peoples
rights, interpreting them in a way that is consistent with Practice
procedures and policies, and current legislation.
- Respecting the privacy, dignity, needs and beliefs of patients,
carers and colleagues.
- Behaving in a manner which is welcoming to and of the individual,
is non-judgmental and respects their circumstances, feelings priorities
and rights.
Personal/Professional
Development:
The post-holder will participate in any training
programme implemented by the Practice as part of this employment, such
training to include:
- Participation in an annual staff performance review.
- Taking responsibility for own development, learning and
performance and demonstrating skills and activities to others who are
undertaking similar work.
Quality:
The post-holder will strive to maintain quality
within the Practice, and will:
- Alert other team members to issues of quality and risk.
- Assess own performance and take accountability for own actions,
either directly or under supervision.
- Lead on induction and training of new staff at site
- Contribute to the effectiveness of the team by reflecting on own
and team activities and making suggestions on ways to improve and
enhance the teams performance.
- Work effectively with individuals in other agencies to meet
patients needs.
- Effectively manage own time, workload and resources.
Communication/Information:
The post-holder should recognize the importance of effective
communication within the practice and management team and will strive to:
- Communicate effectively with other team
members.
- Communicate effectively with patients and
carers.
- Recognise peoples needs for alternative
methods of communication and respond accordingly.
Contribution to
the Implementation of Services:
The post-holder will:
- Apply practice policies, standards and guidance
- Discuss with other members of the team how the policies,
standards and guidelines will affect own work
- Participate in audit where appropriate
Any other
delegated duties considered appropriate to the post.
This job description is not intended to be
exhaustive, but to indicate the main areas of responsibility. It may be changed after consultation with
the post holder. The employee shares with the employer the responsibility for
review and modification of duties.
Suggestions and discussions are welcome.
Policies and
Procedures - the duties and responsibilities of the post will be undertaken
in accordance with the policies, procedures and practices of the Practice,
which may be amended from time to time. You are required to be flexible and
the practice reserves the right to alter such fixed hours as may be
considered necessary to ensure the surgery runs smoothly.
The business operates between the hours of 0700 2100 hours Monday to
Friday (0800 1300 Saturday), with possible requirement for some future
evening and weekend working as the business develops.
