Mid Kent Pcn Frailty/care Home Care Coordinator

6 months ago

Ashford, United Kingdom Sydenham House Medical Group Full time

Mid Kent PCN Frailty/Care Home Care Coordinator

**Hours of work**: **37.5**

**Contract: Permanent**

**Responsible to: Mid Kent PCN Manager**

**Based: Mid Kent PCN (Ashford)**

**2. JOB SUMMARY**

The post holder will be part of the Mid Kent Primary Care Network (PCN) Multi-Disciplinary team (MDT) working alongside healthcare professionals and non-clinical staff to provide a person-centred, proactive approach to healthcare for people with frailty and/or who reside in Care Homes.

The post holder will play an important role within the PCN to proactively identify and work with people, including the frail/elderly, those with long-term conditions and/or living in care homes, to provide coordination and navigation of care and support across health and care services.

The post holder will work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.

This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. The post holder will review patients’ needs and help them and/or their carers to access the services and support they require to understand and manage their own health and wellbeing, referring to other professionals where appropriate.

Please note that the role of a care coordinator is not a clinical role.

**3. DUTIES AND RESPONSIBILITIES OF THE POST**
- Improve continuity of care by acting as a point of contact for residents, families and professionals who visit care homes, such as MDT members and in-reach specialists.
- Support the MDT with the weekly virtual home round through identification of people in need of review, or collation of information on people requiring an MDT review in addition to providing coordination and administrative support to the MDT.
- Attend bi-weekly care home MDT meetings, take comprehensive minutes accurately and document actions and outcomes appropriately on patients’ clinical records.
- Regularly liaise with local Care Homes to gather patient information ahead of MDT meetings, to include any safeguarding concerns, emergencies, hospital admissions and outcomes from these events or any new admissions or discharges.
- To be first point of contact for Care Home Managers to report any concerns or ask for support from PCN practices.
- Provide coordination and navigation for people and their carers across health and care services, working closely with primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
- Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present to the MDT as required.
- Liaise with service providers and clinicians to identify “frequent flyers” and new service users utilising risk stratification tools provided and present to the MDT as required.
- Support completion of new referrals by checking criteria and where this is met, direct referral to the MDT.
- Work sensitively with people, their families and carers to improve their understanding of the patients’ condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
- Help patients/carers manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
- Assist patients/carers to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing the healthcare needs of the people they care for.
- Co-ordinate detailed referrals from Health and Social Care professionals, communicate and answer queries from all disciplines. Organise own day to day activities, plan both straightforward and more complex on-going referrals, together with looking in to the longer term planning of care.
- Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
- Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.
- Support the development of communication channels between GPs, people and their families and carers and other agencies;
- Identify unpaid carers and help them access se

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