Frailty Care Co-ordinator
| Dyddiad hysbysebu: | 10 Hydref 2025 |
|---|---|
| Cyflog: | £23,949.00 bob blwyddyn |
| Gwybodaeth ychwanegol am y cyflog: | £23949.00 a year |
| Oriau: | Llawn Amser |
| Dyddiad cau: | 27 Hydref 2025 |
| Lleoliad: | Hook, RG27 9ED |
| Cwmni: | NHS Jobs |
| Math o swydd: | Parhaol |
| Cyfeirnod swydd: | A3589-25-0020 |
Crynodeb
Job Description Job Purpose Care coordination in General Practice is part of an exciting programme of transformation to develop a new model of care which addresses our ambition to deliver a person-centered coordinated care. Care Coordinators proactively identify and work with specified cohorts of people to support their personalised care requirements, using the available decision support aids and MDTs. They act as the pivotal point of coordination for specified groups of patients and bring together all of a persons identified care and support needs, and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice. This role will initially focus on established patient cohorts but will expand to develop support for our population needing proactive care and integration with our local ICT. Key Responsibilities Coordinate and manage regular multidisciplinary hub meetings, for the Whitewater Frailty Team Manage the appointments of the clinical team. Develop and coordinate the integrated care team hub and development of a shared caseload between community nursing and PCN link nursing Proactively identify and work with a cohort of people identified as needing proactive care to support their personalised care requirements, using the available decision support aids Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance suggested by the MDT Raise awareness of health promotion and NHS health checks in practices Support national screening programmes and immunization programmes in support of the identified patient cohort. This may involve going off-site, i.e; to visit Care Homes. Assist clinicians with the completion of referral forms and monitor referrals to ensure tasks are completed and care delivered by keeping in regular contact Direct liaison with multi agencies to coordinate care for patients Refer to PCN social prescribers, health and wellbeing coach and MIND wellbeing workers where a patient is identified as potentially benefitting from this service To support patient/carer contact roles, and collate patient and carer feedback on their experiences Support Quality and Outcome Frameworks and other DES/LES specifications with service reporting Maintain and develop engagement with all practice staff and encourage best practice Act as the first port of call for patients, in their caseload in relation to their care. Bring together all of a persons identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP), in line with PCSP best practice Help people to manage their needs, answering their queries and supporting them to make appointments Support people to take up training, employment and access appropriate benefits where eligible Raise awareness of shared decision-making and decision support tools, and assist people to be more prepared to have a shared decision-making conversation Ensure that people have good quality information to help them make choices about their care Support people to understand their level of knowledge, skills and confidence their Activation level when engaging with their health and wellbeing, including using the Patient Activation Measure Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing Explore and assist people to access personal health budgets where appropriate Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles Support the coordination and delivery of MDTs within PCNs. Awareness of Safeguarding protocols This role profile is not exhaustive, and you may be directed to complete other tasks according to the skills and requirements for individual roles. These duties will always be reasonable and deemed within the expectations of your position.