Frailty Care Coordinator
2 weeks ago
A new opportunity has arisen for a Frailty Care Coordinator to join the East Warrington Primary Care Networks Multidiciplinary Team.
This is a hugely exciting opportunity to work innovatively with a range of partner organisations to enhance the experience of patients within the area, and work collaboratively with the clinical team to help design and refine the way we improve care in care homes.
The Frailty Care Coordinators role will support the PCN leadership team and GPs in coordinating all key activity including improving access to services, providing advice, and information, and ensuring health and care planning is timely, efficient, and patient-centred. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care.
**Main duties of the job**
The Frailty Care Coordinator will liaise with GPs and practice teams to:
Identify patients who are elderly, frail or who have long term health needs and support.
Support patients to access personalised care and support plans, in line with best practice.
Act as the first port of call for care homes and MDT
Ensure regular and consistent communication with care homes regarding patient progress and any complications, including supporting the coordination of ward rounds
Liaise with primary, secondary and specialist care services as required
Work with the multi-disciplinary team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support
Provide these cohorts of people signposting to identified services in order to maintain their independence and improve their health and well being
Support patient access to cancer screening and prevention services
Visit patients in community, home or care home settings to assess and discuss their care needs involving carers as appropriate.
Assist with personal care plans for individual patients, ensuring preventative actions are detailed to support the appropriate use of services.
Our networks work very closely with our community team and other local Healthcare providers. The networks are adopting new methods of working via an extended clinical workforce which includes GP's, Advanced Nurse Practitioners, Clinical Pharmacists, Practice Nurses, Social Prescribers, First Contact Physios. We are keen to add Care Coordinators to our repertoire as we further develop our teams.Ensure every Care Home resident has a co-produced comprehensive care plan created within seven days of arriving as a resident
Ensure elderly, frail or patients who have long term health needs have a care plan in place
Use provided templates and tools to undertake core assessment elements for inclusion in the care plan
Holistically bring together all of a person’s identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
Identify those elements of the care plan which require specialist input (pharmacist, dietician, nurse, GP etc.) and ensure that these are completed in timely manner
Ensure end of life plans are correctly recorded and where appropriate have been shared with family members.
Identify where technology can be utilised to support continued independence or to aid remote monitoring of health and wellbeing
Communicate effectively and sensitively and use language appropriate to a patient and carer/relative’s condition and level of understanding
Effectively use all methods of communication and be aware of and manage barriers to clear communication
Care home rounds and MDTs:
Overall responsibility for arranging the weekly PCN led MDT meetings (including the weekly virtual Care Home(s) MDT)
The Care Coordinator will:
Schedule the weekly MDT meetings
Manage the meeting agenda items
Identify the patients needing to be prioritized for review that week
Ensure all new residents are reviewed in the MDT within four weeks of arrival
Ensure all residents returning to the home after an acute hospital admission are reviewed by the MDT within seven days of return
Circulate relevant information to MDT members in advance of the meeting.
Ensure actions from the MDT are recorded and care plans are correctly updated
Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
Chase progress against actions and ensure follow up where necessary.
Manage reporting required and associated within the PCN contract for Care Home support
Stakeholder Relationships:
Work with the care home leads to identify skills, education and training needs and assist in the coordination and delivery of an agree training programme
Work as part of the wider holistic team to provide support as necessary
To link with partners to maximise the opportunities available to care home residents including access to on-line peer support and group programmes where t
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