PCN Frailty Team Care Coordinator

Key Responsibilities

• Case Identification:
  • Support the Frailty Nurse as required to undertake digital risk stratification
  • Transpose data onto our clinical systems, ready to enable care coordination
• Holistic Assessment:
  • Support the Frailty Nurse to triage potential patients to determine who receives an assessment
  • Support the Frailty Nurse to determine what action to take with those patients who do not receive an assessment, including ensuring actions are undertaken
  • Contribute to the completion of the assessments as determined by the Frailty Nurse, inputting the information gained into a digital template
• Personalised Care and Support Planning:
  As determined by the Frailty Nurse:
  • Ensure each patient who has an assessment has a Personalised Care and Support Plan that has been discussed and finalised with the patient and any carer/family; this will help to manage their needs and achieve better health and wellbeing outcomes
  • Ensure a ReSPECT plan is completed for each patient who has an assessment
• Coordinated and Multi-Professional Working:
  • Be responsible for coordinating the care of each patient, ensuring close multi-agency and multi-professional working, especially with the local Integrated Neighbourhood Team(s), to facilitate delivery of each patients personalised care and support plan
  • Use and be fully responsible for the care coordination function of our clinical systems as the method of managing and coordinating the care for each patient
  • Be responsible for ensuring relevant colleagues complete their agreed interventions listed in the personalised care and support plan, escalating issues if required to the Frailty Nurse
• Continuity of Care including Review:
  • Be responsible for ensuring each patient who has an assessment has their plans regularly reviewed (e.g. every six months) according to need
  • Be responsible for ensuring each patient who has a significant life event is offered a review e.g. when they have been admitted to hospital on a planned or unplanned basis, or had a fall, or a close family bereavement
• General:
  • Alongside the Frailty Nurse, provide leadership and support to the Frailty Team Administrator as required.
  • Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice
  • Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
  • Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing.
  • Provide co-ordination and navigation across services, helping to ensure people and their carers receive a joined-up service and the appropriate support from the right person at the right time.
  • Work collaboratively with GPs and other General Practice team members within the PCN to proactively identify and manage a caseload, and where appropriate, refer back to other health practitioners within the PCN.
  • Support the co-ordination and delivery of multidisciplinary teams with the PCN, when required.
  • Identify people, using clinical tools, who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations
  • Explore and assist people to access a personal health budget where appropriate and available.
  • Undertake clinical coding to create reliable patient records used for diagnosing accurately, planning treatment, and ensuring patient safety.
  • Competently use clinical systems and templates to capture, and report patient records.
  • Follow-up on communications from out of hospital and in-patient services.
  • Through our clinical systems and tools, maintain records of referrals and interventions to enable monitoring and evaluation of the service.
  • Contribute to risk and impact assessments, monitoring and evaluation of the service.
  • Work with commissioners, Integrated Neighbourhood Team members and other agencies to support and further develop the Team Care Coordinator role and the work of the wider PCN Frailty Team.