Job responsibilities
KEY
RESPONSIBILITIES
Supervision of PCN personalised
care team members.
Acting as first point of
call for team members with queries, questions or ideas.
Being familiar with personalised
and proactive care elements of the Network Contract DES and ensure compliance
throughout the team.
Develop appropriate induction and
training plans for new members of the team; identify training requirements of
existing team members.
Encourage development of the team, overseeing
regular peer support sessions.
Monitor personalised care team
outputs.
Attend local and national
personalised care meetings to provide feedback on local roles and understand
national initiatives.
To work with patients in a
variety of settings, in their own homes or in GP surgeries and other community
settings to signpost them to local services/organisations which the patient
themselves feels would be of benefit to reach their goals.
To work with partner
organisations to support the development and delivery of an integrated care
plan for the client so all their needs are met in a holistic way.
To follow up with clients,
update their records and support them on an ongoing basis.
Be the
patients Advocate to the health and social care system.
Signpost
patients to appropriate services and sources of funding and where appropriate
assist in accessing such funding.
Through
formal MDT and informal means educate clinical and non-clinical staff from the
wider practice/PCN teams. Through verbal
or written advice offer guidance and training on the availability of support
services within the community and how/when patients can access these.
To make and maintain contact
with local health and wellbeing service providers and build a network and
knowledge of referral routes to and from service providers.
To ensure information about
providers and voluntary groups is shared locally across neighbouring networks
To undertake regular
training to extend and update knowledge of health and wellbeing issues.
Ensure your own and the teams'
caseloads are appropriate and regularly review to ensure timely discharges.
DELIVERING A
QUALITY SERVICE
Ensure the team produces accurate, contemporaneous,
and complete records of patient contact, consistent with legislation, policies
and procedures.
Prioritise, organise and manage the
team and your own workload in a manner that maintains and promotes quality and
efficiency.
Assess effectiveness of care delivery through self
and peer review, benchmarking and formal evaluation.
Support and participate in shared learning across
the wider organisation.
COLLABORATIVE
WORKING RELATIONSHIPS
Participate and engage with
stakeholders across the PCN, providing input and guidance to local initiatives
where appropriate.
Liaise, communicate effectively,
and collaborate with member practices within the PCN to ensure smooth running
of personalised care teams and their outputs.
Understand own role and scope, work within this
scope of practice and identify how this may develop over time.
Work as an effective and responsible team member,
supporting others and exploring the mechanisms to develop new ways of working.
Delegate clearly and appropriately, adopting the
principles of safe practice and assessment of competence.
Create clear referral mechanisms to meet patient
need.
Actively works towards developing and maintaining
effective working relationships across the PCN.
Prioritise team and own
workload and ensure effective time-management strategies are embedded.
Work effectively with others to clearly define
values, direction and policies impacting upon care delivery.
Discuss, highlight and work with the team to create
opportunities to improve patient care.
Liaises with other stakeholders as needed for
the collective benefit of patients.
Recognise personal limitations and refer to
more appropriate colleagues when necessary.
Actively works towards developing and
maintaining effecting working relationships across the PCN.
Foster and maintain strong links with all
services across locality.
Explore all potentials for collaborative
working and take opportunities to initiate and sustain such relationships.
EDUCATION, TRAINING &
DEVELOPMENT
Completed (or be working to complete) the NHS
England and NHS improvement online learning programme.
Be enrolled in, undertaking or qualified from
appropriate training as set out by the Personalised Care Institute.
Ongoing, the post holder must attend Peer
Support Networks run by NHS England and NHS Improvement at ICS and/or STP
level.
Understand and demonstrate the characteristics
of a role model to members in the team and/or service.
Disseminate learning and information gained to
other team members in order to share good practice and inform others about current
and future developments (e.g. courses and conferences).
Assess own learning needs and undertake learning as
appropriate.
Assess the learning needs of the wider team, encouraging further
learning.
Develop your learning through regular clinical
supervision sessions with your nominated Clinical Supervisor.