York Road Pcn Care Coordinator Support Worker - Leeds, United Kingdom - South and East Leeds GP Group

South and East Leeds GP Group
South and East Leeds GP Group
Verified Company
Leeds, United Kingdom

1 month ago

Tom O´Connor

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Tom O´Connor

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Description
KEY WORKING REALTIONSHIPS Patients, patients families and carers GPs, nurses and other practice staff PCN pharmacists, social prescribers, primary care mental health team and other PCN attached staff Clinicians, carers and staff Care homes managers, carers, clinicians Community nurses and other allied health professionals


DUTIES AND AREAS OF RESPONSIBILITY:

Work with the PCN to support the personal care requirements for an identified cohort of patients, using available decision support aids.

Support the PCN in bringing together all a patients identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the patient.

Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system Support the practices in identifying appropriate patient cohorts for targeted intervention Update care plan templates on patients records, using correct read codes Attend multidisciplinary meetings across local care organisations indentifying patients in need of review and collating any information required to facilitate their review prior to the meeting.

Take minutes and coordinate.


Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations Undertake delegated clinical procedures within own skills and competence when required (depending on experience and qualifications).

Supporting with Assist patients and carers in managing their own needs, answering their queries and supporting them to address their needs Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care Raise awareness of shared decision making and decision support tools, and assist patients to be more prepared for shared decision making conversations To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN Work in partnership with key providers in the local community to enable improved access to services for patients Explore and assist patients to access personal health budgets where appropriate Support patients 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 Actively engage with, assist, and provide advice to carers, to enable them to sustain their caring role escalating any concerns to the practice when required Work with practices to support delivery of any national and local targets with regard to the GP contract e.g.

PCN DES Safeguarding Identifies and takes appropriate safeguarding action when required in line with local policies Support the practices in safeguarding processes, knowing when to intervene.

Ensuring patients are protected from harm, while protecting their human rights.


Alert your line manager of any significant changes or events which relate to safeguarding Support safeguarding investigations where required Community and Partnership Working Build effective relationships across the PCN and multidisciplinary team to embed the care coordinator role Work in partnership with local providers and community groups to improve collaboration, co-ordination of care and support to the local population Information and Confidentiality Produce and present patient information to relevant groups and meetings to support patient care To update patients records concisely and accurately with relevant information using the practice clinical system To maintain strict confidentiality at all times in line with local policies To identify specific patient cohorts from a variety of data sources to prioritise and coordinate their care needs.

Develop and audit caseloads to monitor outcomes against key performance indicators General To undertake all mandatory training required for the role and the PCN induction programme To develop yourself and actively engage with and participate in training and service redesign activities To attend a formal appraisal with your line manager at least every 12mths.

Contribute to the delivery of public health campaigns e.g. flu and cancer screening through advice or direct support There is a requirement to be able to drive To work at any location in the PCN and/or community in order to meet service needs Perform any other duties as requested by the Primary Care Network as Direct Enhanced Service specifications develop Interviews to be held on 7th or 10th August
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