Care Home & Palliative Care Co-ordinator

1.

Act as the central point of

contact for the North & West PCN Care Home Team.

2.

Co-ordinate the delivery of

Personalised Care and Support Plans and Structured Medication Reviews.

3.

Support the roll out and

coordination of the seasonal vaccination programme.

4.

multi-disciplinary team meetings for Palliative Care MDTs and Care Home MDTs.

5.

Maintain accurate electronic

record for each patient, following case discussions.

6.

Ensure that meeting/MDT actions

are recorded, disseminated and followed up in a timely way.

7.

Support the co-ordination of

Care Home Ward Rounds.

8.

Work closely with all relevant care agencies

to ensure a coordinated delivery of the patients care plan.

9.

Produce a quarterly newsletter

to care homes.

10.

Network and develop strong relationships

with all relevant care agencies.

11.

Working closely with the PCN safeguarding

team and practices to seek advice/escalation as needed on any identified care

home patient safeguarding risks.

The Care Home and Palliative Care Coordinator will work within the PCN

Care Home team, working closely with GP practices to co-ordinate their Palliative

MDT and Care Home MDT meetings, supporting discharges across care settings as

well as admissions and ward rounds for care homes.

The role will provide a

central point of contact and co-ordination for patient care planning for

residents in care home settings (nursing, residential and learning

disabilities).

Working alongside

colleagues in general practice, secondary care, social care, and mental health

as appropriate, providing a single point of access to support co-ordination of

care for patients registered with NW practices. This includes working in

partnership with Care Homes to establish effective working relationships.

Facilitate smooth and

planned discharge and handover between care settings across the health and

social care system, including GP, acute, community, and be responsible for

facilitating inter-agency communication and support.

1.

Act as the main point of contact for the North & West

PCN Care Home Team.

2.

Co-ordinate the delivery of Personalised Care and Support

Plans (PCSP) and Structured Medication Reviews (SMR) for all residents in a

nursing, residential or Learning Disabilities home, utilising EMIS searches and

liaising with the EHCH Clinical Co-Ordinator, PCN Pharmacy Team and GP

practices.

3.

Support the roll out and coordination of the seasonal

vaccination programme, working with each Practice and care home setting.

4.

Co-ordinate the Practice multi-disciplinary team meetings

for Palliative Care MDTs and Care Home MDTs, working alongside the GP Practice leads

and colleague. Ensure a programme of

regular meetings are established, ensuring that all necessary documentation is

circulated in advance, where practical.

5.

Maintain accurate electronic record for each patient,

following case discussions.

6.

Ensure that meeting/MDT actions are recorded, disseminated

and followed up in a timely way; ensure relevant practitioners are aware of

meeting decisions and actions / outcomes.

7.

Support the co-ordination of Care Home Ward Rounds, working

alongside the practice lead, by liaising with each care home and ensuring

patient lists are entered in a timely manner so that the ward round takes place

effectively and efficiently.

8.

Work closely with all relevant care agencies (primary care, secondary

care, community services, Mental Health, Social Services, Ambulance Service,

Voluntary services and other relevant service providers) to ensure a

coordinated delivery of the patients care plan.

9.

Organise and attend additional / relevant meetings when

required within the PCN to support our Practices, including multi-disciplinary

team meetings.

10.

Working with the team, lead on producing a quarterly

newsletter to care homes providing information about the team, key updates and

information that would be relevant to share on a seasonal basis.

11.

Attend quarterly cross PCN meetings with your peers, to

network, build peer support, sharing of information and new ways of improved

working.

and develop strong relationships with all relevant care agencies (primary care,

secondary care, community services, Mental Health, Social Services, Ambulance

Service, Voluntary services and other relevant service providers) to ensure a

coordinated delivery of the patients care plan.

13.

Working closely with the PCN safeguarding team and

practices to seek advice/escalation as needed on any identified care home

patient safeguarding risks. This may

include at times joint projects to support care quality improvement

This beautiful part of the country borders Worcestershire, Shropshire, and Wales. We serve both rural and market town communities, responding to the wide-ranging health needs of our population. Our Primary Care Network (PCN) is highly organised and forward-looking, with strong, collaborative relationships between practices and community providers.

Herefordshire General Practice and Primary Care Networks are supported by the GP Federation, Taurus Healthcare, enabling us to deliver the best of local services while benefiting from the advantages of working at scale.

Qualifications