Pcn Care Coordinator - Smethwick, United Kingdom - Lodge Road Surgery

Lodge Road Surgery
Lodge Road Surgery
Verified Company
Smethwick, United Kingdom

3 weeks ago

Tom O´Connor

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Tom O´Connor

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Description

To provide direct support to the Social Prescribing and Clinical Pharmacy Role and provide a coordinated approach across the PCN member practices.

Complete evaluation, efficiency and reporting of ARRS roles where required to meet NHS/PCN guidelines.

To provide support to the Social Prescriber team in building out and supporting voluntary groups/organisations, develop content and maintaining the accuracy of the Directory of Services.

Set up and managing a group for patients where the demand is not met by CVS or local groups (e.g.

a walking group or coffee morning for the lonely).

Work with Clinical Pharmacist to facilitate group consultations i.e care home patient reviews and support the delivery of the Clinical Pharmacy required outcomes.

Produce monthly news letters for the ARRs roles Organise meeting, produce agendas and minute meeting for the Social Prescribers, Clinical Pharmacists and other ARRs roles and the lead practitioners.

Working with Individual Practice Clinicians and Practice Managers to be responsible for the management of the coordination for the assessment of Learning Disability Patients and other joint projects as needed.


tilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care; support people to utilise decision aids in preparation for a shared decision-making conversation and to take up training and employment help them in accessing appropriate benefits where eligible Work with people to bring together a single personalised care and support plan (PCSP), in line with PCSP best practice.

help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.

Offer support to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure; assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.

Explore and assist people to access personal health budgets where appropriate; work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN; To co-ordinate recall lists for patients who are being monitored for chronic health conditions Identify unpaid carers and help them access services to support them.

Conduct follow-ups on communications from out of hospital and in-patient services.

To follow up patients who have been discharge from hospital to ensure all discharge actions have been carried out and to identify any additional needs to reduce the risk of readmission.

Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances.

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