Job responsibilities
Responsibilities:
• Assist GPs/healthcare professional to identify the eligible cohort as and when need by using approved analytical tool like WSIC, EMIS or practice intelligence.
• Create, maintain and update the register of identified patients.
• To undertake chronic diseases health checks using the skills of the HCA within the remit of acquired competencies.
• To undertake any other duties under the scope of healthcare assistant to assist the PCN with the delivery of holistic care.
• Coach and motivate patients through multiple sessions to identify their needs, set goals, and support them to implement their personalised health and care plan.
• Provide personalised support to individuals, their families and carers to ensure that they are active participants in their own healthcare; empowering them to take more control in manging their own health and physical wellbeing, to live independently, and improve their health outcomes through joint care planning.
• Assist with signposting patient and carers to the appropriate health, mental and social care services within the community.
• Assist patients in building community resilience, and make informed decisions and choices when their health changes.
• Help to identify gaps and develop resources for individuals, such as peer support groups and provide interventions such as self-management and education.
• Supporting people to establish and attain goals set by identifying what is important to them, documenting and producing a patient centred joint care plan.
• Using Digital platforms like to support people to improve their health and wider wellbeing.
• Use of proactive approved analytic tools for smarter targeting of eligible patients.
• Working with the social prescriber, care coordinator and other services to connect them to community-based activities which support their health and wellbeing.
• Contemporaneous recording the data on EMIS and use of templates and codes.
• Amending/redacting the care plans as and when needed and upload it on PKB [if needed].
• Initiation of the jointly created personalised care plan and assisting care coordinators, social prescriber and or other primary care staff in reviewing and meeting the personalised needs of the patients.
• Undertake if not already done by the care coordinator the first Patient Activation Measure (PAM) questionnaire to identify peoples’ levels of knowledge, skills and confidence (‘activation’) and document.
• Undertake the second PAM review, reassess and review the care plans accordingly.
• Work with people with lower activation to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing.
• Asses, advice and encourage patients to jointly agree the action plan and ensure that it is achieved in timely fashion.
• Support people to manage their own health – staying healthy, making informed choices of treatment, managing conditions and avoiding complications’.
• Assist in achieving improved health outcomes when incorporating health coaching in the care of patients with a number of the most prevalent long-term conditions.
• Use conversational skills in their day to day work with patients.
• Build Intensive and integrated approaches to empower people with more complex needs, including those living with multi-morbidity, to experience coordinated care and support that supports them to live well, helps reduce the risk of becoming frail, and minimises the burden of treatment.
• Provide support to local community groups and work with other health, social care and voluntary sector providers to support the patients’ health and well-being holistically.
• Ensure that fellow PCN staff members are made aware of health coaching and social prescribing services and support colleagues to improve their skills and understanding of personalised care, behavioural approaches, and ensuring consistency in the follow up of people’s goals where an MDT is involved.
• Utilise existing IT and MDT channels to screen patients, with an aim to identify those that would benefit from health coaching Training requirements.
• Raise awareness within the PCN of shared decision making and decision support tools and supporting people in shared decision-making conversations.
• Explore and support access to a personal health budget, where appropriate, for their care and support.
Service development/ Training:
• Attending any relevant training organised by the PCN Manager/CD for continuous professional development.
• Attend relevant education courses and study days.
• Be self-motivated with regards to personal development.
• Often appropriate training is on a National Level therefore there is an expectation of a willingness to travel and stay overnight when needed.
• Be involved within clinical supervision sessions with peers and superiors.
• Contribute to the maintenance of a good clinical climate for learners and assist in the in-service training for fellows or trainee
• Participate, attend and promote multi-professional training and learning environment
• Train and assist where practical and reasonable with PCN DES, NSS [National Service Specification] and SNS [Supplementary Network Services] etc.
• Keep up to date with professional research in the relevant areas like – when necessary; participate in pilot projects like LTC, Chatbot etc.
• The post holder may be asked to provide specific training/mentorship to students.
• The Personalised Care Institute (live from April 2020) will set out what training is available and expected for Health coaching link workers.
• Health coaching link workers will be required to be trained in health coaching in line with the NHS England and NHS Improvement summary guide (document currently in development and subject to discussion with GPC England).This is likely to include understanding the basics of social prescribing, plus 4-day health coaching training with regular supervision from health coaching mentor.
Professional Development:
• Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities.
• Involved in one to one meetings with line manager monthly to discuss targets and outcomes achieved.
• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
• Work with your line manager to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.
• Review yearly progress and develop clear plans to achieve results within priorities set by others.
• Participate in the delivery of formal education programmes.
• Demonstrate an understanding of current educational policies relevant to working areas of practice and keep up to date with relevant clinical practice.
Knowledge, Skills and Experience Required:
• Excellent communication skills.
• Good IT skills.
• Good negotiating skills.
• Empathy and good listening skills.
• Capability to manage general anxiety, frustration and manage crisis situations in a positive and proactive manner.
• Work well under pressure and a good sense of humour.
• Prioritisation skills.
• Recognises priorities when problem-solving and identifies deviations from normal pattern and can refer to seniors or GPs when appropriate.
• Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct.
• Involves patients in decisions about prescribed medicines and supporting adherence as per NICE guidelines.
• The practices use the clinical system software ‘EMIS’.
