Job Description

Main Duties Support the Enhanced Health in Care Homes (EHCH) multi-disciplinary (MDT) with day to day duties To work as a key member of the team to help create and get agreement on the structure and processes to support effective MDT meetings To liaise with the registered GP and other practice-based staff in addition to all other providers and services utilising, where appropriate, a multi-disciplinary approach. Support people to improve and maintain their mental, physical, behavioural health and well-being, promoting health and preventing ill health To recognise changes in a patients condition/deterioration which require the intervention of others and know when to refer to the supervising Registered Nurse and other senior colleagues for reassessment of patient care. To recognise and work within the limits of their own competence. To ensure that high standards of nursing care are given and maintained, acting to raise concerns when standards are not being maintained following local policy and procedures.



To be involved with practice initiatives to improve patient safety and care. To act as an advocate for the patient and family, including promoting and protecting their interests, privacy, rights, equality and inclusion. To implement and review individual care plans, self-management plans and to agree trigger thresholds to contact the multi-disciplinary team. Provide enhanced support to Nursing and Residential Care homes with a focus on strengthening relationships and improving access through information sharing, education and advice.



To ensure all residents of Nursing and Residential Care homes have care plans (including dementia where needed) and to provide a holistic review of all people in these homes with updates of their care plans. Communicate any care plans to the GP and any other members of the EHCH multi-disciplinary team and stakeholders involved in the persons care and upload to the relevant records. Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers. To provide support to individuals, their families and carers to take control of their health and well-being, live independently and improve their health outcomes, as a key member of the PCN multi-disciplinary team.



To provide co-ordination and navigation with the aid of digital tools for people and their carers across health and care services. To attend MDT meetings as appropriate. Maintain accurate and up to date records of patient contacts using GP clinical systems and other IM & T systems relevant to the role Support the Clinical Director and member practices in the delivery of the PCN DES specifications. Administrative Duties To ensure that actions points identified with the MDT are recorded and followed, upping 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 an agreed structured process on how this information will be fed into MDTs.



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 Care Plans, Treatment Escalation Plans, DNARs and associated reviews and patient-related correspondence are available at the MDT meetings, liaising with all agencies as appropriate, access and auditing IT systems to ensure relevant information is available. The need to work closely with the PCN Care Co-Ordinators is key to this role. To liaise with acute hospitals regularly, cross referencing admission data with the at risk list, and co-ordinating the sharing of key information between the acute hospitals teams, care/nursing homes and the clinical lead of the EHCH team.



Under the guidance of the supervising Registered Nurse, assist with the discharge process to reduce length of stay in the acute/community hospital setting. Other responsibilities To assist the PCN in setting and realising the PCN vision and values To play a role in the delivery of high-quality primary health care services Maintain a working relationship with local health and care providers to enable service delivery of mutual benefit and build a network and knowledge of referral routes to and from service providers. To establish and maintain effective liaison with stakeholders including health, voluntary, social and education resources, attending relevant meetings as necessary. Refer patients and/or introduce them to appropriate organisations within the PCN footprint and nationally (where appropriate), eg voluntary, statutory (local authority) and local NHS organisations.



To represent the PCN in cross-organisation meetings when agreed, eg locality/CCG meetings. Collate feedback/analysis data on behalf of the PCN to report to the PCN Board and CCG/NHSE as required Support the PCN Manager in providing KPI reports for submission as requested. To be familiar with and follow PCN and practice policies and procedures as appropriate. To have due regard for own personal safety and that of learners, patients and carers, in particular have regard to moving and handling regulations, restraining policies and ensure the safe positioning of self and others.



To decide work priorities for own work area, balancing responsibilities and changing priorities to meet deadlines, ensuring these remain in accordance with those of the service as a whole. Support, supervise and act as a role model to nursing associate students, health care support workers and those new to care roles, reviewing the quality of care they provide, promoting reflection and providing constructive feedback. Support service and practice development to meet the needs of the local population. Be flexible and response to changing requirements Be able to work using own initiative as well as being part of a team.



As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager. The content of this job description will be reviewed regularly in the light of changing service requirements as First Coastal PCN evolves and any such changes will be discussed with the post holder. CONFIDENTIALITY In the course of seeking treatment, patients entrust us with, or allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.



In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the PCN as a business organisation. All such information from any source is to be regarded as strictly confidential. Information relating to patients, carers, colleagues, other healthcare workers or the business of the PCN may only be divulged to authorised persons in accordance with the employing practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.