Care Co-ordinator - Bristol, United Kingdom - Bristol Affinity Network

Description

JOB DESCRIPTION :
Care Co-ordinators

BASED IN One or more sites within our Primary Care Network (TBC)

North & West Bristol


Job overview
An exciting opportunity has arisen for Care Cordinators to be based in our PCN. PCN (Affinity) a collaboration of three local GP Practices in North and West Bristol.

You will be part of a developing multi-disciplinary team (MDT). You will work closely with the MDT providing an efficient, professional, and flexible service to our patients.

You will take a holistic approach to bringing together a patient's care and support needs and draw up personalised care and support plans (PCSP).

You will support the PCN clinical directors in coordinating all key activity including access to services, advice and information, ensuring health and care planning is timely, efficient and patient-centred.

The role includes supporting digital initiatives while co-ordinating and navigating the patients journey through primary care.

A key part of the role will be working with vulnerable and complex patients including regular liaison with local Care Homes.

Main duties of the job

To work with the GPs and other primary care professionals within the PCN to identify and proactively identify and work with a cohort of patients to deliver personal care.

To work in partnership with the Social Prescribing Link Workers (SPLWs) and the wider Community Services including Sirona, to explore care options based on what matters to the person.

To support patients to utilise decision aids in preparation for a shared decisions-making conversation and to help create single personalised care and support plans, in line with best practice.

To help people 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.

This may include supporting people to take up training and employment, self management education courses and access appropriate benefits where eligible.

To support people 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.

To support the PCN in the delivery of the DES specifications


This may include:

• Being an initial contact point for ward rounds with nursing and residential homes, involving GP where needed
• Support and feed into the development of the MDT approach to working with our patients
• Becoming a contact point for patients who are:
• Complex and or frail
• Frequent visitors to the GP
• Recently discharged from hospital or about to be discharged
• Recently attended A and E and would benefit from follow up
• New patients to our list with follow up requirements
• Requiring active signposting to self care services as part of on the day and minor illness approach
• Provision of support for new cancer diagnosis or palliative care
• Provide support to those who have suffered bereavement.
• Support the clinical teams in admisitering care to those on particular disease registers.

About us
Affinity PCN has 30,000 patients across three practices.

Our aim is to help individual practices survive and thrive and to provide a positive patient experience by working together to improve and increase access to primary care services.

COLLABORATIVE WORKING RELATIONSHIPS:

• Works within the primary care team, contributing to leadership of service evaluation and research to promote quality improvement activity.
• Collaborates with other members of the MDT, patients and their carers when managing and coordinating care.
• Uses healthcare technologies to optimise service delivery, patients access, and continuity of care.

MANAGEMENT:

• Demonstrates understanding of the implications of national priorities for the team and/or service.
• Uses resources effectively to manage patient treatment in line with local guidance and makes recommendations for change where improvements can be made.
• Follows professional and organisational policies.

EDUCATION, LEARNING AND DEVELOPMENT:

It is the responsibility of the employee to comply with all organisational and statutory requirements (e.g. health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance).

• Engages in annual appraisal, developing objectives to inform a Personal Development Plan, which may include 360-degree appraisal and use of patient feedback.
• Participate in teaching and training of medical, nursing, and all other practice staff.
• Supports the practice staff and responds to requests for advice and assistance.
• Complete all mandatory and statutory training required by the role.
• Takes responsibility for personal development, learning and performance and maintain education through attendance on any courses and/or study days necessary to ensure that prof