Frailty Care Co-ordinator

The Lakes Medical Practice

The closing date is 29 December 2024

Job summary

We have an exciting opportunity for an enthusiastic Care Coordinator to join our friendly team. This position is well suited to individuals who care about providing high quality, responsive care in a community setting. The role is part of the practice frailty team. Primary care work experience would be beneficial, but not essential. The frailty team carry out proactive and reactive visits for our housebound patients who are frail, require Long Term Conditions ( Asthma/Diabetes/ CHD etc) reviews, Learning Disability and Serious Mental Illness reviews. Do you have the right transferrable skills and experience, are you an excellent communicator and have a flexible approach. If you are resilient, calm under pressure and enjoy a team approach supported by a growing multidisciplinary team. Experience of a similar role and working in primary care is desirable.

Main duties of the job

  • Performing comprehensive assessments on a cohort of patients with moderate / severe frailty identified with a risk stratification tool, or through other members of the practice team.
  • Working with other members of the frailty team and MDTs to plan and visit patients on a proactive or reactive need, working in patients own homes and care settings.
  • Working with the Patients in Care homes, anticipatory care planning and supporting personalised care planning.
  • Advise patients on maintaining health and refer to allied services when a health promotion need is identified.
  • Communicate at all levels within the multidisciplinary team ensuring an effective service is delivered.
  • Maintain accurate, contemporaneous healthcare records appropriate to the consultation
  • Ensure evidenced-based care is delivered at the highest standards ensuring delivery of high-quality patient care
  • The role will also cover reviews for different cohorts of patients, including learning disabilities and mental health illness reviews and Long-Term Condition Reviews.
  • Working as part of the multi disciplinary team including GP, nurse, Pharmacist to provide care for the frail, housebound and care home patients covered by the practice

About us

The Lakes Medical Practice covers Penrith, with a steadily increasing list size of over 11000 patients. There are many opportunities for the successful candidate to broaden his/her clinical experience. We have an expanding team of both medical and non-medical staff who work effectively together to provide a high quality service for the patients. Training and professional development are encouraged. Please note: We reserve the right to close the advert early if sufficient suitably qualified candidates apply.

Date posted

18 December 2024

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Full-time, Part-time, Job share, Flexible working, Compressed hours

Reference number

A5101-24-0013

Job locations

The Health Centre

Bridge Lane

Penrith

Cumbria

CA11 8HW


Job description

Job responsibilities

The frailty care team is based within the practice and the role involves:

Performing comprehensive assessments on a cohort of patients with moderate / severe frailty identified with a risk stratification tool, or through other members of the team.

Use templates to perform the assessment and document on the clinical reporting system EMIS. The assessment will be carried out by the Care coordinator with support and supervision from the wider team as needed.

Working with other members of the practice team to plan and visit patients on a proactive or reactive need, working in patients own homes and care settings.

Working with the frailty team for our patients in Care homes, anticipatory care planning and supporting personalised care planning.

Advise patients on maintaining health and refer to allied services when a health promotion need is identified.

Communicate at all levels within the multidisciplinary team ensuring an effective service is delivered.

Maintain accurate, contemporaneous healthcare records appropriate to the consultation

Ensure evidenced-based care is delivered at the highest standards ensuring delivery of high-quality patient care

Working with the MDT and wider Community Partnership to identify patients appropriate for the proactive care team model.

The role will also cover reviews for different cohorts of patients, including learning disabilities and mental health illness reviews and Long-Term Condition Reviews.

Work as part of the frailty team and the wider practice

Work in collaboration with other care homes and outside agencies to deliver safe effective service

Contribute to the wider MDT discussions as part of the feedback process

Undertake independent assessments and summarise information to feed back to the MDT

Ability to recognise your own limitations and escalate cases to senior colleagues as appropriate

Managing your own diary and patient visits

Participate annually identifying, developing and agreeing your own development plan with your line manager using the Appraisal process.

Participate in regular supervision.

Attend/ complete all mandatory training.

Comply with all local and national policies, procedures and protocols.

Seek advice and support from your line manager whenever necessary.

Ability to work independently and manage workload supported by the wider team.

Comply with the practice lone workers policy when working alone in the community.

All staff members have a duty to report any concerns they have about the safety or well being of adult service users, members of their families, including children. Employees should be aware of their roles & responsibilities to both prevent and respond appropriately to abuse. They should undertake the safeguarding training required for their particular role.

All clinical and non-clinical staff are responsible for infection control.

All staff need a basic working knowledge of risk management. They all have a responsibility to identify and report risks, hazards, incidents, accidents and near misses promptly, in accordance with Policy. All staff must be familiar with emergency procedures, risk management systems and incident management in their workplace.

All employees have a responsibility under the Health and Safety at Work Etc Act 1974 for their own health, safety and welfare and to ensure that the agreed safety procedures are carried out to provide a safe environment for other employees and anyone else that may be affected by the carrying out of their duties.

Job description

Job responsibilities

The frailty care team is based within the practice and the role involves:

Performing comprehensive assessments on a cohort of patients with moderate / severe frailty identified with a risk stratification tool, or through other members of the team.

Use templates to perform the assessment and document on the clinical reporting system EMIS. The assessment will be carried out by the Care coordinator with support and supervision from the wider team as needed.

Working with other members of the practice team to plan and visit patients on a proactive or reactive need, working in patients own homes and care settings.

Working with the frailty team for our patients in Care homes, anticipatory care planning and supporting personalised care planning.

Advise patients on maintaining health and refer to allied services when a health promotion need is identified.

Communicate at all levels within the multidisciplinary team ensuring an effective service is delivered.

Maintain accurate, contemporaneous healthcare records appropriate to the consultation

Ensure evidenced-based care is delivered at the highest standards ensuring delivery of high-quality patient care

Working with the MDT and wider Community Partnership to identify patients appropriate for the proactive care team model.

The role will also cover reviews for different cohorts of patients, including learning disabilities and mental health illness reviews and Long-Term Condition Reviews.

Work as part of the frailty team and the wider practice

Work in collaboration with other care homes and outside agencies to deliver safe effective service

Contribute to the wider MDT discussions as part of the feedback process

Undertake independent assessments and summarise information to feed back to the MDT

Ability to recognise your own limitations and escalate cases to senior colleagues as appropriate

Managing your own diary and patient visits

Participate annually identifying, developing and agreeing your own development plan with your line manager using the Appraisal process.

Participate in regular supervision.

Attend/ complete all mandatory training.

Comply with all local and national policies, procedures and protocols.

Seek advice and support from your line manager whenever necessary.

Ability to work independently and manage workload supported by the wider team.

Comply with the practice lone workers policy when working alone in the community.

All staff members have a duty to report any concerns they have about the safety or well being of adult service users, members of their families, including children. Employees should be aware of their roles & responsibilities to both prevent and respond appropriately to abuse. They should undertake the safeguarding training required for their particular role.

All clinical and non-clinical staff are responsible for infection control.

All staff need a basic working knowledge of risk management. They all have a responsibility to identify and report risks, hazards, incidents, accidents and near misses promptly, in accordance with Policy. All staff must be familiar with emergency procedures, risk management systems and incident management in their workplace.

All employees have a responsibility under the Health and Safety at Work Etc Act 1974 for their own health, safety and welfare and to ensure that the agreed safety procedures are carried out to provide a safe environment for other employees and anyone else that may be affected by the carrying out of their duties.

Person Specification

Experience

Essential

  • Experience of working in primary care
  • Experience of working in a GP practice
  • Experience in dealing with frail and vulnerable patients.
  • Experienced in taking and recording observations and blood samples

Desirable

  • Experienced in the use of Emis web

Qualifications

Essential

  • Educated to GCSE level or Equivalent
  • Care certificate
  • Qualified in Phlebotomy
  • Full UK driving licence

Desirable

  • Care coordination qualification
Person Specification

Experience

Essential

  • Experience of working in primary care
  • Experience of working in a GP practice
  • Experience in dealing with frail and vulnerable patients.
  • Experienced in taking and recording observations and blood samples

Desirable

  • Experienced in the use of Emis web

Qualifications

Essential

  • Educated to GCSE level or Equivalent
  • Care certificate
  • Qualified in Phlebotomy
  • Full UK driving licence

Desirable

  • Care coordination qualification

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

The Lakes Medical Practice

Address

The Health Centre

Bridge Lane

Penrith

Cumbria

CA11 8HW


Employer's website

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

Employer details

Employer name

The Lakes Medical Practice

Address

The Health Centre

Bridge Lane

Penrith

Cumbria

CA11 8HW


Employer's website

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

For questions about the job, contact:

Practice Manager

Helen Parker

Helen.parker41@nhs.net

01768214345

Date posted

18 December 2024

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Full-time, Part-time, Job share, Flexible working, Compressed hours

Reference number

A5101-24-0013

Job locations

The Health Centre

Bridge Lane

Penrith

Cumbria

CA11 8HW


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