Clinical Practice Care Coordinator
3 months ago
ROLE SUMMARY Neighbourhood Working is a new way of strengthening and redesigning community services for a local population. It empowers people and communities to take an active role in their health and wellbeing, with greater choice and control over the care they need. It also supports the improvement, integration, and personalisation of services in Lincolnshire. Core Neighbourhood Working Principles Having a different conversation Delivering Home First principles Enabling self-care and peer support Recognising whats important to me Collective accountability Positive risk taking Assessing immediate needs and addressing barriers to improve quality of life To liaise with the registered GP and other practice based staff in addition to all other providers and services utilising, where appropriate, utilising a multi-disciplinary approach.
To implement and review individual care plans, self-management plans in liaison with the GP practice team. To include advanced care plans, Respect documents, personalised care and support plans Plan and monitor those on GP caseloads and directed by the practice team or identified by the wider Neighbourhood Team at risk of deterioration. Provide enhanced support to Nursing and Residential homes with a focus on strengthening relationships and improving access through information sharing, education, and advice. To ensure all people in Nursing and Residential homes have care plans including advanced care plans, Respect documents, personalised care, and support plans and to provide a holistic review of all people in these homes with updates of their plans.
KEY RESPONSIBILITIES Act as a point of contact between the GP Practice Team, Neighbourhood Team, people and their carers. Develop and maintain a detailed knowledge of local services to enable supported signposting of people with identified need, sharing information with the Neighbourhood Team/Primary Care Network. Liaise with GPs and practice teams to identify people who are elderly, frail or who have long term health need and support. Support the early identification of those with life limiting conditions including those with palliative and end of life symptoms and conditions in order that they are supported to achieve a good end of life experience.
Liaise with primary, secondary and specialist care services as required. Work with Neighbourhood Team colleagues 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 to maintain their independence and improve their health and well-being. Visit people in community, home, or care home settings to assess and discuss their care needs involving carers as appropriate.
Implement personal care plans for individual people, ensuring preventative actions are detailed to support the appropriate use of services. Communicate the care plan to the GP and any other members of the Neighbourhood Team involved in the persons care and upload to the relevant records. Ensure that identified people receive the right level of help at the right time and help them to experience a joined-up service by liaising with relevant members of the Neighbourhood Team. Work with patient, carers and the Neighbourhood Team to encourage the patient to adopt effective self-management and self-help seeking approaches to reduce unnecessary hospital admissions.
Liaise with other agencies to ensure timely and appropriate engagement as required. Support people to access community care assessments as well as carers assessments. Where a personal healthcare budget is allocated provide advice as required regarding the key choices the patient will need to make. Identify unpaid carers and direct them to access services as appropriate to provide them with support.
Identify when urgent action or a step up in care is required and promptly alert the relevant member of the Neighbourhood Team, highlighting any safety concerns. Follow up on communications from out of hospital and in-patient services regarding changes in condition of people to support the practice to respond proactively to potentially unmet needs. Undertake visits or telephone contact to manage people on the PCCs case load following any unplanned hospital admissions where appropriate. Participate in Practice multi-disciplinary meetings to discuss people actively being managed by the Neighbourhood Team and any other people from the PCCs case load needing discussion.
To attend Neighbourhood Team MDT meetings plus any other meetings. Updates between meetings to be shared with the Neighbourhood Team colleagues. Maintain accurate and up to date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e. entering notes onto SystmOne using agreed read codes.
To run regular patient searches using SystmOne to have an up-to-date record of progress of achievement of Key Performance Indicators in line with p
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