Health Inequalities Care Coordinator

4 months ago

Maidstone, United Kingdom Malling PCN Full time

Service Delivery Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids. Support the Practice to establish preferred means of communication to comply with The Accessible Information Standard 2016 and ask about Reasonable Adjustments to meet The Equality Act 2010, to ensure that these are documented/coded and flagged correctly. Establish who is the persons main support and support the practice to ensure this is documented and coded correctly. Identify barriers to accessing health care services, and plan actions and initiatives to overcome and assist easier access to services.

Work with people, their families, and carers to improve their understanding of the Learning Disability Annual Health Check (LD AHC). Work with Practices, people and their families and carers or other support services to prepare for the LDAHC. Review attendance to AHC appointments and follow up those which have not attended or not been supported to attend and support to reschedule as appropriate. Bring together a persons identified care and support needs and support them to explore their options with the clinicians to produce a single personalised care and support plan: The Health Action Plan (HAP).

Help patients and their carers prepare for conversations they have with Primary Care professionals, ensuring that their changing needs are addressed. Follow up on AHC appointment to ensure patients and carers have the support to ensure quality health outcomes. Support the interface between primary care services, specialist community services and acute services, thereby ensuring that people with a learning disability can enjoy good health and receive appropriate treatment when necessary. Develop plans to meet the additional health needs of people with a Learning Disability who come from ethnic communities that experience health inequalities.

Promote and encourage the use of client held information (Communication/ Hospital Passports), for when patients access healthcare services. Support development of communication/hospital when needed. Help people to manage their needs, answering their queries and supporting them to make appointments. 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 good quality, accessible 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. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.

Support the coordination and delivery of Best Interest Decision Making Meetings & Multi-disciplinary Team Meetings within PCNs. Promote and enable access to screening and immunisation programmes. Identify unpaid carers and help them access services to support them. If the carer is a patient at a practice within the PCN, ensure they are correctly coded.

Identify when action or additional support is needed, alerting timely a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. Identify and raise any issues or concerns relating to care provision. Work independently on a day to day basis, making decisions within scope of role and actively seek supervision where required.

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