Community Care Coordinator for East Northants Pcn

Community Coordinators - Ageing Well Teams

BAND 4 -£23,949 -£26,282 depending on experience

Full time (37.5 hours)

East Northants (Full time)

Northamptonshire has the ambition that our older population can be Happy, Healthy and able to maintain independence for as long as possible. Our older population tell us that it can be complicated and confusing to know where best to seek advice and support, that time is often needed to review wider health needs as opposed to ten minute appointments and that social isolation and fear of ageing are major factors on wellbeing. We want to fix this to make sure that all of our older population have personalised and holistic support plans and have their own link person who will ensure timely support is available when needed. We are in the early stages of the journey to deliver on our ambition but already have many exciting improvements underway.

The bedrock of our change programme is the creation of local support teams matching the geographic areas covered by our Primary Care Networks (PCN). These teams combine staff from voluntary sector, adult social care and health, linked to a team of specialists, and led by the Frailty Specialist GP in each PCN. Further information about our exiting transformation programme (Integrated Care Across Northamptonshire (iCAN)) can be found at on the Northamptonshire HCP website.

As a Community Coordinator for the PCN you will be responsible for undertaking comprehensive personalised care and support plans for residents living in care homes and triaging patients identified as frail who live in their own homes to determine what support they need.

A good understanding of services available both within the community and hospital and an interest in frailty so patients can be supported is essential.

As a Community Coordinator you will co-ordinate referrals to ensure patients within the locality receive excellent and timely support. The ability to develop close working relationships with other health and social care partners is an essential aspect of this role. Every team member will have direct access to their local Befriending lead, and lead support workers for Falls and for Dementia.

Through additional training if required you will identify low level equipment needs and instruct for these to be provided and identify how technology can be used to maintain independence and help self management of long term conditions and instruct for digital solutions to be provided.

NHFT is an integrated primary care and mental health Trust, providing physical, mental health and specialty services in both hospital settings and out in the community. Because we put the person at the centre of all we do, we focus on delivering care that is as easy to access as possible. This means many of our services can be provided at home, work or in schools. We also provide health services to various prisons and detention centres in Bedfordshire and Cambridgeshire.

Key responsibilities include;
- Make initial welfare telephone to persons referred to the age well team, to identify their needs.
- Maintain relationships with care home managers and staff in order to support residents within care homes.
- Liaise with GPs and practice teams to identify persons who are elderly, frail or who have long term health needs and support
- Arrange, coordinate and undertake initial home visits and assessments of need within a patient’s own home, making relevant referrals to local service provision.
- Undertake basic health checks such as weight, nutrition, blood pressure monitoring, temperature and personal care needs.
- Support persons within the community to be able to remain as independent as possible within their own home and reduce the risk of crisis support. Tasks may include but not limited to assessment and provision of low level mobility aids, house clearance and cleaning, provision of items to meet basic needs such as emergency food parcels, supporting individuals with housing, finances, medication and follow up appointments.
- Coordinate and attend PCN Frailty Clinics.
- Work alongside families and a person’s wider support network, ensuring their choices, needs and support within their own home are met as a long-term plan.
- Helping persons to access existing groups and events taking place within their communities.
- Document and monitor aspects of patient co-ordination and service delivery, supporting data collection and audit using the practices clinical system as well as organisational data systems
- Maintain an individual case load whilst working cohesively alongside other Age Well partner organisations, supporting a collaborative approach
- Work autonomously with mínimal managerial direction
- To contribute to the ongoing improvement programme by sharing ideas and feedback from both yourself and those you support

For further information on the advertised role, please refer to the job description located under the Supporting Documents heading. The full person