Ageing Well Care Coordinator

Job description

Job responsibilities

With the creation of the 2020/21 Network Direct Enhanced Service (DES) and the introduction of the NHS Additional Role Reimbursement scheme for new primary care roles, an opportunity has arisen for Primary Care Networks (PCNs) to bring in roles that support GP practices, Networks and elements of the Network DES and this role looks to support this work administratively, linking the PCN and practices with the wider health care community, including but not limited to MDTs, social care, community care, pharmacy teams and care homes.

Additionally NHS England have introduced, as part of the NHS Long Term Plan a national Ageing Well Programme.

People in England can now expect to live for far longer than ever before but these extra years of life are not always spent in good health, with many people developing conditions that reduce their independence and quality of life.

The NHS has a key role to play in helping older people manage these long-term conditions, making sure they receive the right kind of support to help them live as well as possible.

The NHS Long Term Plan will give them greater control over the care they receive, with more care and support being offered in or close to peoples homes, rather than in hospital.

We will also make better use of technology such as wearable devices and monitors to support people with long term health problems in new ways, helping them to stay well and live independently for longer.

The role of the Ageing Well Care Coordinator looks to support the elements of the Network DES and the Ageing Well Programme is a mixture of administration, project management and care coordination, supporting teams and practices in delivering the key performance indicators of the Enhanced Health in Care Homes and Ageing Well programmes. More information can be found on the following link: https://www.england.nhs.uk/publication/enhanced-health-in-care-homes-framework/

And

https://www.longtermplan.nhs.uk/areas-of-work/ageing-well/

This role will support the practice care home teams, the care homes and the patients residing in them. Of course, not all older people are residents in a care home, and some will be living at home, either independently or with assistance from unpaid, or paid carers.

Key duties

To methodically action the elements of the project plan against nationally set criteria including but not limited to:

Support the Ageing Well and Enhanced Health in Care Homes Project Plans

Work through the elements of the project plans, aligning practice-based work with PCN and national directives.

Ensure key deliverables are on-track, managed and provided to patients.

Be the champion across the Network for the Ageing Well and Care Home projects.

Link practices, patients, the Network, community and hospital services together by being the conduit to the Network and the practices.

Urgent Community Response

Be the link between the Network and the community provider.

Personalised Care and Support PlansFollow our system to ensurethat all current and new care home residents have a care plan in place that is updated regularly by appropriate individuals such as GPs, ANPs, Nurses, community teams, care home staff.

Assess the need for care plans to be put in place in the wider community for those patients living outside of care homes.

Help professionals, cares and individuals navigate the health and care system

Be the first port of call for queries and problems relating to the navigation of systems. Help guide, direct and support patients and their carers.

Palliative and end of life care

Design and instigate a robust system of ensuring palliative patients are raised by the practice, discussed and MDT. Ensure patients are on the Gold Standard Framework, ensure care plans are in place shared appropriately. Ensure care homes can access palliative care support. Set up training sessions for care home staff to support their palliative patients.

Mental health and Dementia Care

Ensure care plans have appropriate mental health sections within them. Research DiADEM and DEAR-GP as a means to support patients with dementia.

Falls Prevention

Help to administrate any falls prevention schemes.

Technology and Data.

Support care homes and practices in the use of setting up dedicated, monitored care home NHS mail accounts.

Work with Care Homes to ensure that they have patients linked to online access (with patient consent.)

Work with care homes to ensure they fully understand the technology available to them to support the delivery of care to their residents.

Ensure that Structured Medication Reviews for Care Home patients are on target.

Monitor the key deliverables to ensure that practices and the Network achieve any targets via the Quality Outcome Framework, Impact and Investment fund, the Network DES etc.

Work with the Care Coordinator Team to target unwarranted health outcomes and using the local infrastructure (such as the Social Prescriber) to improve the health of the targeted population using recognised Population Health Management tools (such as the DiiS or Electronic Frailty register.).

Work with Network leads to help administrate any MSK, CVD, Dementia and Frailty needs or services.

Person Specification

Experience

Essential

• Experience and/or knowledge of the NHS and Care Homes.
• Data management and analysis skills.
• Awareness of confidentiality and ability to deal appropriately with sensitive or difficult situations.
• Ability to act as a role model demonstrating effective behaviour and leading by example.
• Ability to manage various projects in a timely manner.
• Flexible, versatile, and self-motivated.
• Ability to work as part of a team or on own projects
• Open minded and positive, focused on solutions not problems, a can do attitude.
• Flexible working attitude
• Be a strategic thinker with an ability to be innovative

Desirable

• Healthcare Assistant experience
• Experience of working in a health and social care environment.
• Practical experience of managing change.
• SystmOne knowledge

Qualifications

Essential

• GCSE grade A to C in English and Maths

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Wimborne and Ferndown PCN

Address

Rodways Corner

Wimborne

Dorset

BH21 1AP

Employer's website

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