Frailty Care Coordinator

Job Purpose The Frailty Care Coordinator role is seen as a critical and evolving post to support the development of a proactive frailty service operating at Integrated Neighbourhood Team (INT) level. The Frailty Care Coordinator will support multi-disciplinary teams (MDTs) within the INT and PCN to deliver effective, co-ordinated and personalised care for patients in care homes and for a cohort of elderly and frail patients. The post holder will work closely with the multi-disciplinary team to support INT and PCN on-going patient case management and to support patient cohorts which have been identified for support by the INT and PCN. This will involve working with the GP surgeries and linking in with a range of community health and social care services, care homes, the VCSE and third party services. The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. The post holder must at all times be aware of the need for confidentiality and integrity. They will also need a basic knowledge of Health and Social Care terminology and eligibility criteria and current team structures and pathways. Key working relationships Frailty GP lead Patients, patients families and carers GPs, nurses and other practice staff Care home managers, clinicians, carers and staff Frailty GP Lead, Case Manager and Geriatrician Community nurses and other allied health professionals Community pharmacists and support staff Responsibilities underpinning the role To assist the team to develop one single personalised care and support plan for patients to be held on the patients medical records and in the care homes. Holistically bring together all of a patients identified care and support needs, and explore options to meet these with a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. To develop and support patient Treatment Escalation Plans (TEPs) and Advanced Care Planning (ACP). Help patients to manage their needs by answering queries, assisting with making/ managing appointments, and ensuring that patients have good verbal or written information to help them make choices about their care. Provide coordination and navigation for patients and their carers across health and social care services, working closely with social prescribing link workers and other primary care professionals. Explore and assist people to access personal health budgets or appropriate benefits where eligible. Support patients to utilise decision aids in preparation for a shared decision-making conversation. Work with GPs and other primary care professionals and colleagues within the INT and PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the INT. Raise awareness within the INT of shared decision making and decision support tools. Raise awareness of how to identify patients who may benefit from shared decision making and support INT staff and patients to be more prepared to have shared decision-making conversations. To act as first point of contact for professionals, GPs, care homes, community services and the third sector across the INT. Responsible for the organisation of MDT meetings and supporting the coordination and delivery of MDTs within the INT and PCN. Responsible for a register of patients identified at INT MDT coordinating patient care across services and the INT. Review discharge summaries and conduct post discharge follow up call to review patients needs and arrange a package of care if needed. Manage the recall of patients in need of bloods/BPs and other diagnostic test for medication reviews and/or green eclipse alerts supporting with patient observations where necessary. To act as a support contact for elderly and frail patients. To support end of life care and palliative care. To provide support for patients with learning disabilities. To follow appropriate safeguarding procedures. To undertake patient observations blood pressure, venepuncture, body temperature, respiratory rate and oxygen saturation. To support housebound and care home patients with ability to independently travel essential in role delivery. Administrative Reponsibilities To work as a key member of the MDT to help support the development of effective MDT meetings. To take a lead in IT ensuring all MDT staff have access to Microsoft Teams and have adequate equipment to participate in video meetings. Lead on the IT facilitation of the MDT meetings using Microsoft teams including sending out invites to appropriate members of the MDT. To take minutes of MDT meetings and ensure that action points identified are recorded and followed up within a set timescale. Under guidance from their line manager take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team. To work with the wider MDT to identify appropriate case managers* for high-risk patients to ensure that patients are reviewed, and anticipatory care plans are developed Ensure that all patients Anticipatory Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available To liaise with acute hospitals and coordinate the sharing of key information between the acute hospital teams and the MDT team. Act as a non-clinical contact for the care home to assist with case management of patients at risk of admission; working with the ANP / GP to identify sources of support in liaison with case managers. To accurately read code and update/maintain patients records for anticipatory care. To update care plan templates within Systm1 ensuring accuracy with read codes used. Maintain an accurate record of two week wait referrals for practice audits. To provide support with safeguarding admin (adults and child). Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute / community hospital setting This list is not exhaustive and may be subject to change Workforce Responsibility The post holder must remain up to date with mandatory training as required Environmental Factors The post holder will be required to drive The post holder may be required to undertake duties at any location in the community in order to meets service needs Concentration required for data analysis, tracking patients and meetings, frequent interruptions requiring attention and re-prioritisation of work Input data for a significant period Equal Opportunities Arbennek Healthcare is committed to an equal opportunities policy that affirms that all staff should be afforded equality of treatment and opportunity in employment irrespective of sexuality, marital status, race, religion/belief, ethnic origin, age, or disability. All staff are required to observe this policy in their behaviour to fellow employees. Confidentiality All employees are required to observe the strictest confidence with regard to any patient/client information that they may have access to, or accidentally gain knowledge of, in the course of their duties. All employees are required to observe the strictest confidence regarding any information relating to the work of Arbennek Healthcare and its employees. You are required not to disclose any confidential information either during or after your employment with Arbennek Healthcare, other than in accordance with the relevant professional codes. Failure to comply with these regulations whilst in the employment of Arbennek Healthcare could result in action being taken. Data Protection All employees must adhere to the Arbennek Healthcare Policy on the Protection and use of Personal Information, which provides guidance on the use and disclosure of information. The practices of North Cornwall Coast also have a range of policies for the use of computer equipment and computer-generated information. These policies detail the employees legal obligations and include references to current legislation. Health and safety Arbennek Healthcare expects all staff to have a commitment to promoting and maintaining a safe and healthy environment and be responsible for their own and others welfare. Risk Management You will be responsible for adopting the risk management culture and ensuring that you identify and assess all risks to your systems, processes and environment and report such risks for inclusion within the risk register of the practices of Arbennek Healthcare. You will also attend mandatory and statutory training, report all incidents/accidents, including near misses, and report unsafe occurrences as laid down within the Incidents and Accidents Policy. Other duties The above job description is designed to give an overview of the tasks and responsibilities for this position; it is not intended to be exhaustive. The Strategic Manager will meet annually with the post holder to review and ensure that this position remains relevant and in accordance with the evolving needs of the PCN. Job description Job responsibilities Job Purpose The Frailty Care Coordinator role is seen as a critical and evolving post to support the development of a proactive frailty service operating at Integrated Neighbourhood Team (INT) level. The Frailty Care Coordinator will support multi-disciplinary teams (MDTs) within the INT and PCN to deliver effective, co-ordinated and personalised care for patients in care homes and for a cohort of elderly and frail patients. The post holder will work closely with the multi-disciplinary team to support INT and PCN on-going patient case management and to support patient cohorts which have been identified for support by the INT and PCN. This will involve working with the GP surgeries and linking in with a range of community health and social care services, care homes, the VCSE and third party services. The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. The post holder must at all times be aware of the need for confidentiality and integrity. They will also need a basic knowledge of Health and Social Care terminology and eligibility criteria and current team structures and pathways. Key working relationships Frailty GP lead Patients, patients families and carers GPs, nurses and other practice staff Care home managers, clinicians, carers and staff Frailty GP Lead, Case Manager and Geriatrician Community nurses and other allied health professionals Community pharmacists and support staff Responsibilities underpinning the role To assist the team to develop one single personalised care and support plan for patients to be held on the patients medical records and in the care homes. Holistically bring together all of a patients identified care and support needs, and explore options to meet these with a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. To develop and support patient Treatment Escalation Plans (TEPs) and Advanced Care Planning (ACP). Help patients to manage their needs by answering queries, assisting with making/ managing appointments, and ensuring that patients have good verbal or written information to help them make choices about their care. Provide coordination and navigation for patients and their carers across health and social care services, working closely with social prescribing link workers and other primary care professionals. Explore and assist people to access personal health budgets or appropriate benefits where eligible. Support patients to utilise decision aids in preparation for a shared decision-making conversation. Work with GPs and other primary care professionals and colleagues within the INT and PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the INT. Raise awareness within the INT of shared decision making and decision support tools. Raise awareness of how to identify patients who may benefit from shared decision making and support INT staff and patients to be more prepared to have shared decision-making conversations. To act as first point of contact for professionals, GPs, care homes, community services and the third sector across the INT. Responsible for the organisation of MDT meetings and supporting the coordination and delivery of MDTs within the INT and PCN. Responsible for a register of patients identified at INT MDT coordinating patient care across services and the INT. Review discharge summaries and conduct post discharge follow up call to review patients needs and arrange a package of care if needed. Manage the recall of patients in need of bloods/BPs and other diagnostic test for medication reviews and/or green eclipse alerts supporting with patient observations where necessary. To act as a support contact for elderly and frail patients. To support end of life care and palliative care. To provide support for patients with learning disabilities. To follow appropriate safeguarding procedures. To undertake patient observations blood pressure, venepuncture, body temperature, respiratory rate and oxygen saturation. To support housebound and care home patients with ability to independently travel essential in role delivery. Administrative Reponsibilities To work as a key member of the MDT to help support the development of effective MDT meetings. To take a lead in IT ensuring all MDT staff have access to Microsoft Teams and have adequate equipment to participate in video meetings. Lead on the IT facilitation of the MDT meetings using Microsoft teams including sending out invites to appropriate members of the MDT. To take minutes of MDT meetings and ensure that action points identified are recorded and followed up within a set timescale. Under guidance from their line manager take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team. To work with the wider MDT to identify appropriate case managers* for high-risk patients to ensure that patients are reviewed, and anticipatory care plans are developed Ensure that all patients Anticipatory Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available To liaise with acute hospitals and coordinate the sharing of key information between the acute hospital teams and the MDT team. Act as a non-clinical contact for the care home to assist with case management of patients at risk of admission; working with the ANP / GP to identify sources of support in liaison with case managers. To accurately read code and update/maintain patients records for anticipatory care. To update care plan templates within Systm1 ensuring accuracy with read codes used. Maintain an accurate record of two week wait referrals for practice audits. To provide support with safeguarding admin (adults and child). Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute / community hospital setting This list is not exhaustive and may be subject to change Workforce Responsibility The post holder must remain up to date with mandatory training as required Environmental Factors The post holder will be required to drive The post holder may be required to undertake duties at any location in the community in order to meets service needs Concentration required for data analysis, tracking patients and meetings, frequent interruptions requiring attention and re-prioritisation of work Input data for a significant period Equal Opportunities Arbennek Healthcare is committed to an equal opportunities policy that affirms that all staff should be afforded equality of treatment and opportunity in employment irrespective of sexuality, marital status, race, religion/belief, ethnic origin, age, or disability. All staff are required to observe this policy in their behaviour to fellow employees. Confidentiality All employees are required to observe the strictest confidence with regard to any patient/client information that they may have access to, or accidentally gain knowledge of, in the course of their duties. All employees are required to observe the strictest confidence regarding any information relating to the work of Arbennek Healthcare and its employees. You are required not to disclose any confidential information either during or after your employment with Arbennek Healthcare, other than in accordance with the relevant professional codes. Failure to comply with these regulations whilst in the employment of Arbennek Healthcare could result in action being taken. Data Protection All employees must adhere to the Arbennek Healthcare Policy on the Protection and use of Personal Information, which provides guidance on the use and disclosure of information. The practices of North Cornwall Coast also have a range of policies for the use of computer equipment and computer-generated information. These policies detail the employees legal obligations and include references to current legislation. Health and safety Arbennek Healthcare expects all staff to have a commitment to promoting and maintaining a safe and healthy environment and be responsible for their own and others welfare. Risk Management You will be responsible for adopting the risk management culture and ensuring that you identify and assess all risks to your systems, processes and environment and report such risks for inclusion within the risk register of the practices of Arbennek Healthcare. You will also attend mandatory and statutory training, report all incidents/accidents, including near misses, and report unsafe occurrences as laid down within the Incidents and Accidents Policy. Other duties The above job description is designed to give an overview of the tasks and responsibilities for this position; it is not intended to be exhaustive. The Strategic Manager will meet annually with the post holder to review and ensure that this position remains relevant and in accordance with the evolving needs of the PCN.