Pcn Frailty Care Coordinator - Leeds, United Kingdom - Dr G A Lees & Partners

Description

As a member of the Armley Primary Care Network (PCN) Frailty Team, the Frailty Care Coordinator/HCA (FCC/HCA) will assist with the delivery of national and local agenda for care of frail patients within their own homes, to enable them to maintain their independence in a safe environment.

They will work alongside, and under the supervision of, registered practitioners to carry out a range of healthcare activities and duties.

This work will usually be undertaken in the patients home; however, specific PCN clinics may also require support.

The role includes undertaking delegated clinical tasks and procedures such as phlebotomy, BP recordings, diabetic reviews, foot checks, stroke and kidney disease reviews in the patients home or at one of our 3 GP surgeries.

Working strictly in accordance with specific guidelines and agreed protocols, the FCC/HCA will assist with the ongoing support of patients, families and carers in a professional manner - using resources economically and efficiently.

In line with PCN policy, the FCC/HCA will update patient records using both EMIS and SystmOne, ensuring entries are accurate, relevant, and timely and that they appropriately communicate the care provided.

The FCC/HCA will participate in multidisciplinary and case management meetings, where appropriate, and develop and maintain effective working relationships with health and social care colleagues and other agencies to ensure that frail and complex patients and those with long term conditions receive a consistent, integrated response to all contacts/referrals.

Duties will be undertaken in an autonomous manner with advice from the practice care teams and GPs as appropriate.

The FCC/HCA will understand and follow procedures and policies on information governance, with strict adherence to protocols regarding the sharing of personal and confidential information between different organisations/individuals.

Appropriate competency-based training and all mandatory training will need to be completed.

Main Job Responsibilities Holistically support patients with mild to severe frailty within the community Undertake frailty reviews of housebound patients for PCN practice sites via home visit, or occasionally via telephone Review patient needs and help them access the services and the support they require to understand and manage their own health and wellbeing Refer patients to services within the area that are most appropriate for them Conduct low level clinical screening such as dementia screening, blood pressure checks and venepuncture as directed by the lead health professional.

(Where relevant training has been received) Carry out low level falls assessment/screening and provide advice and information on falls prevention, including referral for equipment where necessary.

Assist in the formulation and review of care plans to ensure all care is reflecting the patients needs and wishes Visit housebound patients at the request of PCN practices for Healthcare Assistant-appropriate tasks whilst ensuring these do not detract from core frailty work Ensure patient records are updated appropriately and consultations recorded using the appropriate template Liaise with each practice to maintain frailty registers Liaise with each practice to prioritise visits Work within the scope of HCA practice Identify social isolation and loneliness, being proactive in signposting to relevant resources to empower patients to remain active and engaged within their communities Identify and recognise deterioration in an individuals health and act promptly to refer to relevant health professional to minimise risk or where appropriate, avoid hospital admission Assist practices in the achievement of targets related to frail and housebound patients Develop and maintain knowledge and relationships with our practices and local services Work with local statutory, voluntary and independent organisations to ensure referrals are made appropriately and maximise the availability of local resources.

Take all reasonable precautions to ensure the health and safety of service users and self, understanding and following risk assessments as instructed.

To maintain close links with other services in line with Safeguarding procedures and make other appropriate interventions and escalation.

Ensure that GPs, practice nurses, practice pharmacists and other members of the primary care team understand the FCC/HCA role, and which patients may particularly benefit from their input Work with the Armley PCN and its leadership team to develop and evaluate the effectiveness of this role.

Core Responsibilities:
Frailty reviews for patients within Armley PCN who are house dependent Assisting each practice to maintain up to date frailty registers Help to raise awareness of health and wellbeing and how it can be promoted Assisting with the collection and collation of data on needs related to health and wellbeing

Additional Responsibilities:
On occasion, not as a matter of course, for pract