Job summary
The post-holder will provide proactive, person-centered support for patients living with dementia and their carers within Shrewsbury PCN. They will coordinate support across health, social care, voluntary and community services to ensure patients receive timely assessments, appropriate interventions and continuous support throughout their dementia journey. The role aims to improve outcomes, enhance quality of life and reduce avoidable crises or hospital admissions.
Main duties of the job
Early Identification & Diagnosis Support
- Facilitate timely dementia screening and referrals for diagnosis through close working with GPs and the memory clinic.
- Support patients and families throughout the diagnostic process.
Holistic Care Planning
- Regularly review personalised care plans reflecting patient and carer needs, wishes and preferences.
- Coordinate advance care planning discussions to respect future care choices.
Coordination of Services
- Act as the main point of contact to coordinate between primary care, secondary care, social care, mental health and voluntary sector services.
- Ensure smooth transitions between care settings, particularly around hospital admissions and discharges.
Carer Support
- Identify carers and assess their needs.
- Provide emotional support, signpost to respite services and connect carers to support networks.
Education and Empowerment
- Provide accessible information and guidance about dementia to patients and carers.
- Promote self-management strategies and enable independent living for as long as possible.
Health Inequality Reduction
- Ensure equitable access to dementia care and support among underserved and minority communities within the PCN.
About us
Shrewsbury PCN is made up of 11 GP practices supporting over 104,000 patients in and around Shrewsbury, Shropshire.
We are passionate about leading a network that is supportive and collaborative, where members and staff feel appreciated and empowered to make a difference. Our ambition is to deliver exceptional care and have a positive impact on the community we serve.
Job description
Job responsibilities
Main duties and responsibilities
- Maintain and regularly update a register of all patients with dementia in the PCN.
- Complete and review personalised care plans annually for all registered patients with dementia.
- Establish a robust referral and follow-up system with local memory services and dementia support organisations.
- Organise monthly multi-agency meetings to review complex dementia cases, to include: Practice Dementia Leads and Administrator, Alzheimer Link workers, Admiral Nurses, Carer Support Practitioner - Council, Memory Service - SATH, Shropshire Council Adult Social Care.
- Complete and document carer assessments with appropriate follow-up and support.
- Conduct annual patient and carer satisfaction surveys to guide service improvements.
- Deliver community engagement events or awareness sessions (e.g., Dementia Friends sessions, Dementia Action Week activities).
- Collect and report data to support the PCN's quality improvement objectives, including metrics or unplanned admissions and delayed discharges.
Job description
Job responsibilities
Main duties and responsibilities
- Maintain and regularly update a register of all patients with dementia in the PCN.
- Complete and review personalised care plans annually for all registered patients with dementia.
- Establish a robust referral and follow-up system with local memory services and dementia support organisations.
- Organise monthly multi-agency meetings to review complex dementia cases, to include: Practice Dementia Leads and Administrator, Alzheimer Link workers, Admiral Nurses, Carer Support Practitioner - Council, Memory Service - SATH, Shropshire Council Adult Social Care.
- Complete and document carer assessments with appropriate follow-up and support.
- Conduct annual patient and carer satisfaction surveys to guide service improvements.
- Deliver community engagement events or awareness sessions (e.g., Dementia Friends sessions, Dementia Action Week activities).
- Collect and report data to support the PCN's quality improvement objectives, including metrics or unplanned admissions and delayed discharges.
Person Specification
Qualifications
Essential
- Educated to GCSE level or equivalent
Experience
Essential
- Care background (e.g. nursing, social care, allied health, or experienced care navigator)
- Experience in coordinating care across different services and organisations
- Experience of working in a role that requires a high degree of autonomy
- Experience of working across a variety of multidisciplinary teams
Desirable
- Experience in working in primary care or community settings
- Experience in carer support or patient advocacy
Other
Essential
- Meet DBS reference standards and criminal records checks
- Access to own transport / full clean driving license
- Ability to travel across the locality as and when needed
Knowledge and skills
Essential
- An understanding of dementia and its impact on patients and families
- Strong organisational skills, including planning, prioritising, time management and record keeping
- Ability to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients
- Ability to recognise and work within limits of competence and seek advice when needed
- Ability to prioritise own workload
- Computer efficient with the ability to apply effective IT systems
- Excellent written and verbal communication skills
- Excellent team working skills
- Able to work independently, showing initative
Desirable
- Knowledge of primary care and how it operates
- Able to use clinical information systems
Personal Attributes
Essential
- Ability to demonstrate personal accountability, resilience and work well under pressure
- Flexible and adaptable to team and service needs
- Reliable, punctual and confident
Person Specification
Qualifications
Essential
- Educated to GCSE level or equivalent
Experience
Essential
- Care background (e.g. nursing, social care, allied health, or experienced care navigator)
- Experience in coordinating care across different services and organisations
- Experience of working in a role that requires a high degree of autonomy
- Experience of working across a variety of multidisciplinary teams
Desirable
- Experience in working in primary care or community settings
- Experience in carer support or patient advocacy
Other
Essential
- Meet DBS reference standards and criminal records checks
- Access to own transport / full clean driving license
- Ability to travel across the locality as and when needed
Knowledge and skills
Essential
- An understanding of dementia and its impact on patients and families
- Strong organisational skills, including planning, prioritising, time management and record keeping
- Ability to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients
- Ability to recognise and work within limits of competence and seek advice when needed
- Ability to prioritise own workload
- Computer efficient with the ability to apply effective IT systems
- Excellent written and verbal communication skills
- Excellent team working skills
- Able to work independently, showing initative
Desirable
- Knowledge of primary care and how it operates
- Able to use clinical information systems
Personal Attributes
Essential
- Ability to demonstrate personal accountability, resilience and work well under pressure
- Flexible and adaptable to team and service needs
- Reliable, punctual and confident
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.
