Long Term Conditions and Care Homes Care

7 months ago

Stockport, United Kingdom Viaduct Care Full time

**Job Purpose**: Care Co-ordinator roles are new to Primary Care and we are looking to recruit a Long Term Conditions and Care Home Care Co-ordinator within the SES Primary Care Network (PCN). This role will involve working with patients with a range of presentations and their families and carers. The care co-ordinator will be integral in overseeing the interdisciplinary care and will be responsible for co-ordinating a package of care and support from a variety of specialists who may be working with the patient. The care co-ordinator will support all key activity across the PCN; supporting the PCN manager and associated practices by co-ordinating activity and providing an efficient, well organised administrative and operational support to the clinicians and managers in the network to ensure effective timely delivery of the PCN objectives.

**Main Roles & Responsibilities**: To work with the GPs and other primary care professionals within the PCN to proactively identify and support patients requiring additional input due to their presentation with particular focus on those patients unable to come to the surgery. Be responsible for running weekly EMIS searches, contacting patients to arrange appointments, whether in their own homes or visiting in nursing homes/care homes. Data collection and submission, filing, general admin etc. Bring together all a persons identified care and support needs and what matters to them; explore the options to address these in a single personalised care and support plan.

Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation. Ensure that people have high-quality health information to help them make choices about their care. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing; explore and assist people to access personal health budgets where appropriate. Support the coordination and delivery of multidisciplinary teams within PCN.

Contribute to increasing uptake of national screening programmes throughout the PCN. Provide coordination and navigation for individuals and their carers across health and care services, working closely with social prescribing link workers and other primary care roles. To help patients to manage their needs through answering queries, making, and managing appointments. Assist and coordinate practices in meeting PCN Des and Impact and Investment Fund (IIF) targets, and practice Quality Outcomes Framework (QoF) targets.

Responsible for coordinating any joint projects, e.g. vaccination and any associated administration. To support with venepuncture and NHS Health Checks (pulse measurement, blood pressure monitoring, height and weight measurement and waist measurement) where necessary. Take responsibility for liaising and communicating with each care home.

Identify support needs and options for treatment pathways. Ensure all relevant patient information, including historical information, compliance issues, long term conditions are managed, and symptoms are provided and escalated to the Care Home GP & team. Liaison between the home and GP Practice to co-ordinate weekly ward round lists, urgent visit requests and medication requests outside of the ward round times. Co-ordinating SIPS team/medicines optimisation in Care Homes and to co-ordinate SMRs.

To work alongside digital services providers to enable electronic care planning when developed/implemented. To support clinical teams with advanced care planning/end of life care planning as appropriate. To assist with validation of and communication with people registered under a lasting power of attorney. It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role.

All employees of Viaduct Care must not, without prior permission, disclose any information regarding patients or staff. In circumstances where it is known that a member of staff has communicated information to an unauthorised person, those staff will be liable to dismissal. Moreover, the Data Protection Act 2018 also renders an individual liable to prosecution in the event of unauthorised disclosure of information. Health and Safety All employees must be aware of the responsibilities placed on them under the Health and Safety at Work Act 1974 to ensure that the agreed safety procedures are carried out to maintain a safe working environment for patients, visitors and employees.

Review and ensure systems are in place for the proactive management of risk registers. Infection Control All employees of Viaduct Care are required to contribute to the management of infection control and be proactive in awareness raising and prevention. Ensure that all guidelines, protocols and procedures undertaken within the service are in line

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