Complex Health Coordinator

2 weeks ago

Peterborough, United Kingdom Lakeside Healthcare Group Full time

This may involve using skills where patients have difficulties in communication e.g. Hearing loss, diminished sight, mental health issues, speech problems, cognitive impairment, behavioural problems, and pain. Conduct assessments and discussions about care needs in various settings, being mindful of confidentiality principles and risk issues. To maintain accurate patient records, (ensuring these are recorded on SystmOne clinical system within 24 hours) write letters, make onward referrals where indicated, using relevant systems, and ensuring a clearly documented rational for any action taken.

Work with individuals to support their personalized care needs and create care plans, following through on agreed actions and taking responsibility for supporting the individual to achieve their agreed goals. To identify when patients need interventions from other services and initiate onward referral as indicated, within the GP practice team, third sector services, and including to the senior clinician(s) within the project. To be involved in the development, delivery, and evaluation of patient group work initiatives, in conjunction with a senior clinician, demonstrating initiative and curiosity about how to achieve positive patient outcomes through this therapeutic approach. To keep the individual at the centre of their wellbeing plan, raising awareness of shared decision making and provide information to help individuals make informed choices about their care.

Support individuals in their health and wellbeing, including through self-management education, providing relevant resources and information, and accessing personal health budgets, training, employment, and benefits. Coordinate care services and work closely with other primary care roles. Assist with monitoring and actioning of referrals and communicate effectively with other practices in the network about this, to ensure timely management of referrals. Project and Operational requirements To maintain integrity of Horizontal Project data in relevant system and provide written and verbal feedback regarding individual and group outcomes, generating report data to monitor project progress.

Actively participate in the practice of supervision, keeping records and a portfolio to evidence skill and personal development. To attend relevant external and internal courses to extend knowledge or gain relevant skills to improve clinical practice as identified as part of the Appraisal process. Assist with all project documentation and timelines for successful execution of population health projects. Support the coordination and delivery of multi-disciplinary teams working within the network.

To work effectively within the team structure, the PCN wider team and liaise appropriately with members of the project team and other agencies by attending project meetings, and case reviews. To inform/update all members of the multi-disciplinary team, service users and appropriate others of changes involving health and wellbeing, progress and other relevant matters that pertain to the support and well-being of the individual. Establish good working relationships with other practices in the network to facilitate effective teamwork and liaison, and to seek collaboration within project delivery. To plan and prioritise own workload.

To support the development of the project outcomes and other staff within the team. To work autonomously under the direction of a senior clinician(s) within the project which aims to target the populations identified within the Core 20 Plus 5 NHS approach. Other Be willing to undertake travel to various locations to carry out duties of the post. To safeguard the health, well-being, and safety of the patients we work with, some of whom maybe classed as vulnerable people or adults at risk.

In the event of a risk to a Patient becoming apparent or if concerns arise about a vulnerable persons welfare, to immediately report these concerns in line with the appropriate policy and procedure. NB. in addition to these responsibilities, employees are required to carry out such other duties as may be reasonably required. Lakeside Healthcare reserves the right to vary this job description from time to time in line with business needs.

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