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Community Coordinator Age Well
3 months ago
As a Community Coordinator in one of the local Age Well Teams you will be responsible for undertaking comprehensive holistic assessments of identified frail older people, usually in their own homes, to create personalised care plans which will assist the person to live well in their own environment, manage their long-term conditions, reduce isolation and improve their general wellbeing and quality of life.
A good understanding of services available both within the community and hospital and an interest in frailty so patients can be supported is essential.
The ability to develop close working relationships with other health and social care partners is an essential aspect of this role.
Every team member will have direct access to their local Befriending lead, and lead support workers for Falls and for Dementia.
Through additional training if required you will identify low level equipment needs and instruct for these to be provided and identify how technology can be used to maintain independence and help self management of long term conditions and instruct for digital solutions to be provided.
- Make initial welfare telephone calls to persons including A&E discharges to identify needs.
Arrange, coordinate and undertake initial home visits and assessments of need within a patient's own home, making relevant referrals to local service provision.
Undertake basic health checks such as weight, nutrition, blood pressure monitoring, temperature and personal care needs.Support persons within the community to be able to remain as independent as possible within their own home and reduce the risk of crisis support.
Tasks may include but not limited to assessment and provision of low level mobility aids, house clearance and cleaning, provision of items to meet basic needs such as emergency food parcels, supporting individuals with housing, finances, medication and follow up appointments.
Coordinate and attend PCN Frailty Clinics.Work alongside families and a person's wider support network, ensuring their choices, needs and support within their own home are met as a long-term plan.
Helping persons to access existing groups and events taking place within their communities.Document and monitor aspects of patient co-ordination and service delivery, supporting data collection and audit using the practices clinical system as well as organisational data systems
NHFT is an integrated primary care and mental health Trust, providing physical, mental health and specialty services in both hospital settings and out in the community.
Because we put the person at the centre of all we do, we focus on delivering care that is as easy to access as possible.
This means many of our services can be provided at home, work or in schools. We also provide health services to various prisons and detention centres in Bedfordshire and Cambridgeshire.
NHFT promotes a culture of learning to improve the care and safety of our patients and staff, which focuses on people who enable our Trust to be 'outstanding' by supporting opportunity, innovation, development and growth.
