Job responsibilities
ROLE OBJECTIVES:
The post holder, working closely with the PCN team, Care Homes, GPs and existing community services will:
- Coordinate Multi-Disciplinary Team meetings for people living in care homes
- Utilise Population Health Intelligence to proactively identify care home residents and work with the PCN team to enable the PCN team to deliver personalised care
- Utilise Population Health Intelligence tools where needed to support other patients in the PCN.
ADDITIONAL RESPONSIBILITIES
- Be responsible for daily updating of patients on e-HealthScope Workflow to identify care residents to support the PCN team with identifying community pathways that might prevent hospital admission and for identifying potential gaps in care
- Be responsible for arranging, attending and minuting Care home Multi-Disciplinary Team Meetings
- Proactively prepare any actions prior to the MDT ensuring all relevant clinicians are present
- To record patient interventions on relevant electronic database systems (e.g. SystmOne) and contribute to report generation, analysis and production
- Follow up on all forward actions resulting from MDT discussions
- Be responsible for logging and making referrals
- To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team and providing information to any member of the PCN Team in order to ease processes and communication in agreement with data protection protocol
- To be responsible for recording, reporting and producing evaluation reports which will include evaluation detailing effectiveness outcomes of new roles.
- To be customer (patient, carer, GP) focused when representing the service
- To work collaboratively with other teams and services to maintain an effective and efficient service
- To offer appropriate support and guidance to patients and their families/carers
- To plan / organise work using own initiative, whilst being able to work as a valuable member of a team
- To have excellent IT skills, to include Microsoft Office, Outlook and Excel
- To undertake general office duties to support the role
- To work effectively as part of a team to provide cover for Care Coordination Teams when required and to be flexible regarding working hours to meet the needs of the service
- To ensure all electronic records are updated and complete within the agreed time-scales
- To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleague
- Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested
- Support the PCN team by inputting into the overall strategy development and programming of work streams by applying knowledge and understanding of programme and project management
- Work with key personnel in the PCN to develop & support collective general practice projects including areas of federated working
- Work towards completing the appropriate training to deliver and support the Comprehensive Model for Personalised Care
- Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested
- To participate in the review and appraisal process
- To carry out any other reasonable duties as requested by a manager to ensure quality of service
- To participate in any relevant training/courses/conferences
- Complete mandatory training
- Use clinical systems for record keeping, audit and evaluation
- Develop and implement data collection systems that will provide accurate and timely data.
- Maintain confidentiality
PROFESSIONAL DEVELOPMENT / PERSONAL PERFORMANCE
- Identify learning needs, plan, implement and evaluate programmes of education to meet identified need.
- Establish own support mechanisms to enable structured reflection, including supervision, development of supportive networks mentoring and coaching.
- Participate in and undertake supervision of colleagues on an individual or group
- Participate in the Divisional appraisal System and demonstrate the achievement of agreed personal objectives.
PHYSICAL AND MENTAL SKILLS
- The post holder should be physically fit for the role with the necessary keyboard and IT skills.
- The post holder would be expected to coordinate delivery of care in line with the pathway for heart failure patients, performing comprehensive assessment of patient nursing needs, plan, implement and evaluate care delivery according to changing health care needs.
- Required to communicate across the health community and with patients / carers where the nature of the information given may be sensitive and could be disputed.
- The post holder should be empathetic and skilled in listening, persuasion and negotiation, and recognizes Care, Compassion, Courage, Competency, Communication, and Commitment in their role.
EFFORT AND ENVIRONMENT
Physical effort
- Frequent long periods of time spent writing up patient related information within agreed time limits. There is a need for speed and accuracy. This is a continuous requirement throughout each day.
- Prolonged periods of time spent in a sitting position at a computer screen when answering the telephone and writing clinical information in patients notes at the same time.
- Frequent periods through the day of standing and walking to liaise with other Health and Social Professionals. The post holder is occasionally required to lift equipment several times throughout the week e.g. files or boxes or stationery.
Mental Effort
- Prioritising work is essential, as often many tasks are required to be undertaken simultaneously. The post holder is required to work under pressure and meet deadlines.
Emotional Effort
- Potential distressing situations e.g. liaising with terminally ill patients and their carers/families. Exposure to vulnerable groups.
WORKING CONDITIONS
- To function effectively across a variety of environments
- Occasionally the post holder may be exposed to aggressive verbal abuse/physical aggression from patients, relatives and other health and social care professionals over the telephone or face to face.
SUPPLEMENTARY DUTIES AND RESPONSIBILITIES
Mobility
- Employees may be required to work at any of the other sites within the organisation subject to consultation. The organisation is in a period of rapid change due to developments and rationalisation of services. This will lead to modification of structures and job descriptions. The post holder will be expected to co-operate with changes subject to consultation, at any time throughout the duration of their contract
Health and Safety
- Employees have a legal responsibility not to endanger themselves, fellow employees and others by their individual acts or omissions. The post holder is required to comply with the requirements of any policy or procedure issued in respect of minimising the risk of injury or disease.
Data Protection and Confidentiality
- All employees are subject to the requirements of the Data Protection Act 2018 and must maintain strict confidentiality in respect of patient, client and staff records.
Safeguarding Responsibilities
- The organisation takes the issues of Safeguarding Children, Adults and addressing domestic violence very seriously. All employees have a responsibility to support the organisation in our duties by:
- Attending mandatory training on Safeguarding children and adults.
- Making sure they are familiar with their and the organisations requirements under relevant legislation.
- Adhering to all relevant national and local policies, procedures, practice guidance (e.g. LSCB Child Protection Procedures and Practice Guidance) and professional codes.
- Reporting any concerns to the appropriate authority.
Smoking and Health
- The organisation has a no smoking policy throughout its premises, including buildings and grounds.
Equality and Diversity
- The organisation is committed to promoting equal opportunities to achieve equity of access, experience and outcomes and to recognising and valuing peoples differences. This applies to all activities as a service provider, as an employer and as a commissioner.
Information Management and Technology (IM&T)
- All staff are expected to utilise the relevant national and local IM&T systems necessary to undertake their role.
Flexible Working
- The organisation is committed to offering flexible, modern employment practices, which recognise that all staff need to strike a sensible balance between home and work life. All requests to work flexibly will be considered.
Resource Management
- Ensure the effective and efficient use of physical and financial resources, make recommendations regarding supplies and equipment
Freedom to Act
- Adhere to organisations policies and procedures, guided by occupational policies and procedures in primary and secondary care.
- Maintain up to date skills and knowledge and maintain awareness of professional issues.
- Maintain a professional portfolio.
- Works without supervision plans own workload, guidance sought if required from line manager and colleagues.
- The post holder should demonstrate good organization and time management skills
Reasonable Adjustments
- The organisation is seeking to promote the employment of disabled people and will make any adjustments considered reasonable to the above duties under the terms of the Equality Act 2010 to accommodate a suitable disabled candidate.
Please download the supporting documentation for full role details and to assist with your application.
