Ageing Well Care Coordinator

5 months ago

Wimborne, United Kingdom Wimborne and Ferndown PCN Full time

Key duties To methodically action the elements of the project plan against nationally set criteria including but not limited to: Support the Ageing Well and Enhanced Health in Care Homes Project Plans Work through the elements of the project plans, aligning practice-based work with PCN and national directives. Ensure key deliverables are on-track, managed and provided to patients. Be the champion across the Network for the Ageing Well and Care Home projects. Link practices, patients, the Network, community and hospital services together by being the conduit to the Network and the practices.

Urgent Community Response Be the link between the Network and the community provider. Personalised Care and Support Plans Maintain a system to ensure that all current and new care home residents have a care plan in place that is updated regularly by appropriate individuals such as GPs, ANPs, Nurses, community teams, care home staff. Assess the need for care plans to be put in place in the wider community for those patients living outside of care homes. Help professionals, cares and individuals navigate the health and care system Be the first port of call for queries and problems relating to the navigation of systems.

Help guide, direct and support patients and their carers. Palliative and end of life care Design and instigate a robust system of ensuring palliative patients are raised by the practice, discussed and MDT. Ensure patients are on the Gold Standard Framework, ensure care plans are in place shared appropriately. Ensure care homes can access palliative care support.

Set up training sessions for care home staff to support their palliative patients. Mental health and Dementia Care Ensure care plans have appropriate mental health sections within them. Research DiADEM and DEAR-GP as a means to support patients with dementia. Project work Work with the PCN Administration Team to target unwarranted health outcomes and using the local infrastructure (such as the Social Prescriber) to improve the health of the targeted population using recognised Population Health Management tools (such as the DiiS or Electronic Frailty register.).

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