Job responsibilities
JOB PURPOSE:
The Wellbeing
Care Coordinator will have a key role in the recently formed Wellbeing Team for
N&W Primary Care Network supporting the network’s population to live
healthy, positive, and fulfilling lives.
The Wellbeing Team will identify and work with individuals in need
of proactive support with the aim of encouraging independence, a healthy
lifestyle, mental wellbeing, and social connectivity. We will identify areas of
health inequality within our locality and work with the primary care team, and
community partners to engage with the population and understand existing gaps
in provision. This will include increasing uptake in cancer screening and other
health initiatives, early intervention to manage long term conditions, and
supporting people to access health and community services.
As a member of the Wellbeing Team the Care Coordinator will work
within our network of GP Practices to provide a central co-ordination role for
patient care planning. The role will involve working one to one with patients
who need extra support, helping them to be actively involved in managing their
care and supported in making choices that are right for them.
The Care Coordinator will be an essential team member working with
a Health & Wellbeing Coach, Social Prescriber and Primary Care Team. They
will provide a single point of access for staff and patients, providing
feedback to the practices, troubleshooting, and escalating actions as
necessary, providing advocacy for service users.
Main
Responsibilities
1.
Facilitate and ensure the effective delivery of patient-centred,
personalised health and social care plans for patients, monitoring progress and
reporting outcomes, contributing to patient reviews and care planning within
appropriate time frames.
2.
Explain the management of a patient’s pathway to clinical staff,
liaising between services and service users, contacting services using the
appropriate procedures/referral mechanisms.
3. Work closely with all relevant care
agencies (primary care, secondary care, community services, Mental Health,
Social Services, Ambulance Service, Voluntary services and other relevant
service providers) to ensure a coordinated delivery of the patient’s care plan,
without requiring a further referral from the GP.
4.
Maintain accurate records and statistical returns as required by
the CCG, including providing patient-related information for entering into
Clinical Reporting Systems, within the required time frame.
5.
Ensure that a proper handover of care between different settings
has taken place, including mutual transfer of all organisations’ communications
& patient notes and ensuring care packages are set up.
6.
Collect data on patients/carers for recognised outcome measure and
document for service interpretation. Ensure all patient notes are updated to
reflect any changes, including details on plans
7.
Managing operational meeting processes, identifying patients for
discussion and working closely with clinicians to define and lead the meetings.
Organise and attend relevant meetings when required including multi-disciplinary
team meetings, ensure a programme of regular meetings is established, ensuring
that all necessary documentation is circulated in advance.
8.
Ensure that meeting actions are recorded, disseminated and
followed up in a timely way; ensure relevant practitioners are aware of meeting
decisions and actions / outcomes, and chase for action resolution and update.
9.
Network and develop strong relationships with all levels of the
NHS’s key local players including the CCG, GPs and other primary care
contractors, Social Services, Mental Health Trusts, Community Trusts, and other
providers including the voluntary sector.
10. Be a contact point for GPs /
practices and establish systems and processes which will ensure a timely and
appropriate response to queries from clinicians and other stakeholders.
Patient Services
·
To
provide services to patients via clinics in the PCN, domiciliary visits and in
residential and nursing homes, and to deliver care plans that improve the
quality of patient care.
·
To
be present at patient group meetings or other appropriate events to give
advice.
·
To
assist with the production of patient information leaflets and posters and support
awareness projects throughout the year.
·
To
help plan, develop and support the introduction of new working processes within
the PCN to optimise the patient uptake.
COMMUNICATIONS AND WORKING RELATIONSHIPS
PERSONAL DEVELOPMENT
- To attend mandatory training and
fire lectures regularly and assist with fire policy/evacuation procedure
when necessary.
- To keep up to date with and attend
training on revisions to information systems or changes in protocols for
the inputting of data in the light of Local and national initiatives. To adhere to agreed protocols at all
times.
- To participate in Individual
Performance Review and Personal Development plans on an annual basis and
to undertake training and development as identified within these
discussions and as indicated by the requirements of the post.
CLINICAL GOVERNANCE AND QUALITY ASSURANCE
- To
realise the importance of confidentiality when dealing with patients and
staff, particularly when giving or receiving information over the
telephone in accordance with the Data Protection Act.
- Maintain
the high standards of the service by contributing towards individual, team
and service objectives and acting at all times in the best interest of
patients.
- To
accurately collect, collate and input data to Information Systems as
required by procedures to ensure that patient database records are up to
date and accurate.
- To participate in Individual
Performance Review and Personal Development plans on an annual basis and
to undertake training and development as identified within these
discussions and as indicated by the requirements of the post.
INFORMATION
GOVERNANCE
- Taurus Healthcare requires its
staff to comply with Information Governance related standards and policies
at all times when dealing with confidential information, which includes
any information relating to the business of the company and its service
users and employees.
- All Taurus Healthcare staff are
bound by a duty of confidentiality and must conduct their duties in line
with the NHS Confidentiality Code of Practice, Data Protection Act and
Freedom of information Act.
- Post-holders must maintain high
standards of quality in corporate and clinical record keeping ensuring
information is always recorded accurately and kept up to date. The
post-holder must only access information, whether paper, electronic or in
other media, which is authorised to them as part of their duties.
- All Information obtained or held
during the post-holder’s period of employment that relates to the business
of the company and its service users and employees will remain the
property of the Taurus Healthcare. Information may be subject to
disclosure under legislation at the Company’s discretion and in line with
national rules on exemption.
- Any breach of confidentiality or computer misuse could
lead to disciplinary action, and in serious cases could result in
dismissal. Breaches after the post-holder’s employment has ended could
result in the Company taking legal action against them.
HEALTH AND
SAFETY
- To have responsibility for health,
safety and welfare of self and others at work. This includes being conversant with
Trust Health & Safety policies and procedures and ensuring incidents,
accidents and near misses are reported; taking part in the risk management
process and carrying out tasks/using equipment only when competent to do
so.
- Be responsible for ensuring the
general environment is clear of all hazards.
- All staff have a responsibility to apprise themselves
of how the prevention of the spread of infection relates to their
role. They have a responsibility to ensure they are aware of Company
policies and procedures in relation to infection prevention and control,
and ensure that they comply with them in fulfilling their role.
EQUALITY AND DIVERSITY
- Respect
the privacy, dignity, needs and beliefs of patients, carers and colleagues.
- Act
in a way that recognises the importance of peoples rights, interpreting
them in a way that is consistent with Taurus procedures / policies and
current legislations.
- Act
as a chaperone as needed.
- Behaving in a
manner which is welcoming to and of the individual, is non-judgmental and
respects their circumstances, feelings priorities and rights.
This job
description may be amended by management through consultation with the post
holder in order to reflect changes in, or to, the job.
