Proactive Care Coordinator

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KEY DUTIES

CLINICAL & PROFESSIONAL RESPONSIBILITIES

• Complete aspects of Contact Cares assessment and review work, following Service standard operational procedures and processes.
• To include completion of duty screening calls and onward referrals following referrals received by GP/professional.
• Independently complete assessments in patient homes regularly, often vulnerable/homeless/self-neglect patients/service users. Assessments include a baseline of clinical observations, such as Blood Pressure, Oxygen Saturations, Temperature, Blood Glucose monitoring. These observations are recorded in the client’s electronic case notes with a notification sent to the clinician for interpretation.

• Utilise knowledge in the prevention of pressure sores and use prescribed pressure relieving equipment and skin products where appropriate
• Administer delegated medicines for injection

• Implement and evaluate a plan of care for simple wound management, as directed by a registered practitioner

• Utilise clinical skills appropriately to enhance the delivery of patient care g. Venepuncture, removal clips/sutures

• Health and Social Care questions are asked in order to establish the correct/most appropriate service/referral inclusive of service users typically reluctant to engage.
• Venepuncture for a variety of investigations both routine and urgent, to aid hospital avoidance.
• Identify and use opportunities to promote healthy lifestyles e.g. diet, exercise.
• Have knowledge and information on local services available to patients whilst considering a range of options during ongoing patient assessments, analysing service users’ needs.
• Act as advocate and facilitator to resolve issues that may be perceived as barriers to care.
• Develop a partnership approach to working, in order to empower the patient and carers, in diverse situations/cases.
• Support people in accessing appropriate information and support, by sign-posting to a range of support services and take an approach which helps people to self-manage where appropriate.
• Make pre-planned outbound telephone calls to patients to assess on-going needs to enable a proactive prevention approach.
• To maintain accurate, clear, concise and contemporaneous records as per Trust policy and communicate information to members of the Team as necessary.
• Liaise and communicate with referrers, patients, relatives, carers, and other health and social care professionals to support and coordinate care.
• Communicate with other members of the integrated care team if patient/service user is in need of further interventions to prevent unplanned hospital admission.
• Be the interface between patients and/or carers, Primary Care, Community Health and Social Care, ensuring the needs of the patient is incorporated into individual care plans.
• Deal in a professional, helpful and sensitive manner with patients, service users, staff and other agencies by telephone or face to face, taking messages, advising service users about visits, referring other issues as appropriate and answering routine enquiries.
• Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers e.g. Community Matron.
• To attend the ‘Hospitals Frequent Attenders MDT Meeting’, to provide patient information and link with GP practices to help reduce A&E admissions.
• To actively promote and inform GP’s, District Nurses and Contact Cares of other Services and initiatives available to support patients and prevent hospital admissions/readmissions.

ADMINISTRATIVE RESPONSIBILITIES

• Independently manage and prioritise their own workload on a daily basis, within parameters of role, and deal with the competing demands placed on the integrated care team.
• Coordinate and manage the administrative functions for the integrated Multi-disciplinary Team Meetings. This will include organising and adjusting meetings and tasks on behalf of a number of stakeholders, responding to urgent clinical tasks as required.
• Be the point of liaison for service users receiving care coordination and interface with all professionals involved in service users care including primary and secondary care, community services, carers and other relevant groups.
• Requirement to receive telephone calls/correspondence from partnership health professionals, relating to single point of access, where calls are received and triaged. Decisions are based on the individual service criteria as to the route the call will take, with guidance from professionals regarding clinical/non-clinical facts/situations where a suitable course of action needs to be determined.
• Co-ordinate the handover between Acute to Community providers to facilitate the safe and effective transition of care between services, in order to provide seamless support for patients, their families and carers.
• Liaise with medical and nursing personnel in primary, secondary and specialist centres about patients and service provision related matters including statutory and voluntary providers of care.
• Take responsibility for the facilitation of regular Multidisciplinary Team Meetings, which involves coordinating and organising partnership professionals. The information in relation to these meetings from a wide range of other strategies/projects is to be collated and delivered prior to the MDT.
• Devise and maintain efficient filing, clerical and office systems, and provide administrative support, including photocopying, faxing and dealing with other forms as required.
• Establish and maintain a frailty register.
• Contributes, implements and establishes standard operating procedures and processes for administrative and clinical systems.

INFORMATION TECHNOLOGY

• To be proficient in using Microsoft office packages and other identified IT, systems and support other team members in their use.
• Support the MDT and CCG Commissioners in developing their risk-profiling strategies and tools to identify ‘at risk’ patients, including those patients who have multiple hospital admissions, ED attendances and unplanned out of hours care and implement and agreed structured process on how this information will be fed into MDT’s.
• Extract relevant patient information / data off a number of IT systems e.g. IAS LAS/Shared Care Record (St Helen’s Council), EDMS (St Helen’s & Knowsley Teaching Hospital), EMIS (General Practice), Aristotle (Arden and Gem), RIO to be communicated into the Multi-disciplinary Team Meetings, which will contribute to appropriate, effective and timely care planning.
• Following MDT Meetings, update the Service records contemporaneously on the relevant IT systems as agreed.
• Support completion of patient/service user referrals, record electronically and feedback to team members.
• Maintain Excel database for the collection and analysis of complex data relating to MDT performance measurements.
• Compile and send monthly statistical reports as requested.
• RESEARCH & AUDIT
• Extract caseload information from the patient/service systems as required and undertake analysis of caseload information for audit and performance management purposes, including running reports and converting data into charts and tables for sharing with the team.
• Support and contribute to audit processes, governance, research, clinical research trials and service development.
• Access to patient identifiable information via Aristotle IT intelligence to establish patients ‘at risk’ of admissions in line with continuing projects/pilots to aid hospital avoidance.

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TEACHING & TRAINING RESPONSBILITIES

• Demonstrate self-directed learning, actively seeking role development opportunities to enhance practice, knowledge and role progression.
• Utilise informal and formal learning opportunities both independently and with others.
• Participate in an individual performance review on an annual basis and be proactive in Continuous Professional Development.
• Identify personal education needs and skills development with line manager.
• Maintain a personal development plan and competency portfolio.
• Support the training requirements of clinicians so that they are able to access and use data systems appropriately, coaching individuals where necessary.
• Contribute to the education of student nurses/therapists and health care assistants as required