Job responsibilities
JOB PURPOSE
The post holder will work within the Care Navigation Team, providing coordination, administrative and support to the Clinical teams and other members of the PCN.
The post holder will work closely with General Practices and existing services to support the coordination and delivery of multidisciplinary team meetings.
The post holder will support the PCN to proactively identify hospital admissions avoidance and gaps in care:
- Support the provision of early intervention and treatment as a preventative action to prevent avoidable exacerbations or admissions through proactive case finding and identifying the appropriate support.
- To coordinate care for patients through the development of multidisciplinary working and joint goal setting in conjunction with other multi-professional team members to meet the patient’s needs.
KEY RESPONSIBILITIES
Role Objectives:
The post holder working closely with the GP’s, Community Services, PCN Team, and Care Home Team where appropriate and will:
- Provide support for GP Practices, patients, carers, and professionals to access and navigate resources and services which will help those living with the effects of long-term conditions including frailty.
- Coordinate Multi-Disciplinary Team meetings for GPs.
- Utilise Population Health Intelligence to proactively identify high risk patients to avoid admissions and readmissions to hospital and work closely with the PCN & Community teams to enable them 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 patients to support the PCN team with correct community pathways that may prevent hospital admission and to identify potential gaps in care
- Be responsible for arranging, attending, and minuting Multi-Disciplinary Team Meetings
- Proactively prepare any actions prior to the MDT ensuring all relevant health care professionals and Social care members are present
- To record patient interventions on relevant electronic database systems (e.g., SystmOne and e-HealthScope) 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 Navigation and PCN Care Coordinators 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 timescales
- To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleagues
- Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support were 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
- Work closely and in partnership with the Social Prescribing Link Workers & Health & Wellbeing Coaches
- 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.
Please download the supporting documentation for full role details and to assist with your application.
