Clinical Care Coordinator - Liverpool, United Kingdom - Primary Care Knowsley

Description

Job Purpose The main objectives of the role are: To support delivery of the PCNs contractual requirements To support individuals identified as frail or at risk of frailty to manage their health and wellbeing To work both as part of the general practice team and a wider multi-disciplinary team, playing a role in coordinating care and support to individuals They will respond to referrals from GP surgeries or Care Homes supporting the arrangements for appropriate care and ensuring that unplanned, changing needs are addressed and that individuals are accessing appropriate support either from statutory or third sector services Key Relationships Clinical Director PCN Management Team PCN Care Coordination Team PCN Clinical Team GPs in PCN Member Practices Practice Managers in PCN Member Practices PCN Care Homes Mersey Care Community Teams Social Prescribing Link Workers (SPLWs) Health and Wellbeing Coaches (HWBC) Core Duties To support the Learning Disability Health Check Process To deliver Learning Disability Health Checks To support active case finding of patients with undiagnosed Cardiovascular disease To deliver blood pressure review clinics, ensuring the hypertension protocol is adhered to at all times To deliver cardiovascular disease prevention health checks (NHS Health Check) to patients within the PCN population, identifying those who require further intervention and support (e.g. pre-diabetes, statin therapy, weight management etc) To support and deliver vaccination clinics to patients (e.g. shingles, influenza pneumococcal) with the support of a clinical supervisor To refer patients to social prescribing link workers for support with non-medical holistic support, thus helping the PCN to achieve its objectives in referrals to SPLWs To conduct home visits appropriate to the competency to ensure the health and wellbeing of the patient population Care Homes To visit and support patients in Care Home settings to assess whether there are any unmet health or care needs, including after discharge from hospital To complete holistic person-centred care planning, commencing the CGA process Communicate regularly with Care Homes to establish if there are new residents or residents recently discharged from hospital and commence the CGA process or coordinate the review of existing CGA Where unmet are identified to complete relevant referrals into wider clinical and third sector services To coordinate and attend the weekly PCN Care Home MDT meetings Other Duties Work within all relevant service policies and procedural guidelines Maintain administration systems and workspace in a clean and tidy condition Work flexibly to meet the needs of the PMO Develop own knowledge to meet own objectives and changes in service Operate a high standard of probity Undertake any other duties appropriate to the grade and purpose of the role as may be agreed between the post holder and their line manager Communication Build and communicate effective working relationships within the PMO, across the PCN Member practices and with a wide array of statutory and voluntary organisations for the benefit of patient care and to facilitate good working relationships Participate in team meetings Recognise the roles of other colleagues within the organisation and their role in patient care Demonstrate the use of appropriate communication to gain the co-operation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals, other NHS/private organisations) Demonstrate ability to work as a member of a team Promote effective communication and relationships within the team Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary Managing Self and Others Manage own time, workload and resources effectively Work within the limits of your own competency, seeking advice or support when needed Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the service performance Assess own performance and take accountability for own actions, either directly or under supervision Manage and Use Information Alert other team members to issues of quality and risk Assess own performance and take accountability for own actions, either directly or under supervision Effectively manage own time, workload and resources Make effective use of up-to-date information technology in order to collate accurate and timely information as and when required by the PMO Confidentialty In the course of seeking treatment, patients entrust us with and allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff respect their privacy and act appropriately.

In the performance of the duties outlined in this Job Description, the post holder may have access to confidential information relating to patients and their carers, practice staff and othe