KEY RESPONSIBILITIES: Working with patients: Work with individual patients, their families and carers, using a holistic approach, to identify their goals for care, and agree a personalised care and support plan for their care. Support delivery of those care plans by coordinating input from a range of different professionals and services, and helping patients and their carers/family to navigate across health and social care services. Work as part of the primary care team, coordinating care between GPs, Practice Nurses, Clinical Pharmacists, Social Prescribing Link Worker and Health and Wellbeing Coach. Help patients to manage their needs through answering queries, being a first point of contact in the practice, and by making and managing appointments.
Support patients to utilise decision aids in preparation for a shared decision-making conversations and ensure that they, and their carers/family have access to good quality written and verbal information to help them male choices about their care. Support patients to take up training and employment where appropriate, and to access benefits where eligible. Help patients to access personal health budgets where appropriate. Make use of tools such as Patient Activation Measure when engaging with patients.
Help patients to access self-management education courses, peer support or other interventions that support them in improving their health and well being. Undertake regular reviews of the personalised care and support plans developed with patients. Work in line with national best practice when developing personalised care and support plans. Work with patients over the phone, in person in the practice or, for those who are housebound, where necessary carry out home visits.
Administration: Use practice level reports to identify suitable cohorts of patients to deliver personalised care Provide accurate and timely data to support audit and monitoring of the service, and any data returns as required by the ICB Keep accurate and up to date records of contacts with patients and their carers/families in the patient’s GP record and in their care plan Follow up documentation required for care planning from other organisations, making use of Local Care Record where useful Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations’ communications and patients notes, and ensuring care packages are set up Collect data on patients/carers for recognised outcome measures and document for service interpretation Managing any necessary meetings to support care planning, identifying patients for discussion, organising the meeting and circulating required information beforehand as necessary Ensure that meeting actions are recorded, disseminated and followed up in a timely way. 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 and any such changes will be discussed with the post holder

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