Paramedic/Anticipatory Care Nurse – Taunton Deane West PCN

Taunton Deane West Primary Care Network

Job Title:

Taunton Deane West - PCN Anticipatory Care Nurse / Paramedic

Band:

7

Base:

GP Practice in PCN: TBC

Responsible For:

Supporting Taunton Deane West Primary Care Network (PCN) with the anticipatory care part of the DES and proactive care project

Accountable To:

Clinical Director Dr Rachel Yates

Pay/Hours

TBC

Fixed Term 6 months

Annual Leave entitlement:

25 days annual leave entitlement + Bank Holiday’s

Job Purpose

The post holder will be responsible for the proactive care provision of support to Taunton Deane West Primary Care Network which will include attending and working with the multidisciplinary team (MDT), who are responsible for managing the care of people registered with practices within Taunton Deane West PCN. They will attend the weekly proactive care MDT and practice MDTS and help identification of people in need of review, to fit with the project and themes of Ageing well. The referral pathway may vary from GPs to other practitioners, village agents, social prescribers with the aim of providing a patient centred, cost-effective approach to the care of patients with multiple morbidities and illness trajectories that will deteriorate over time.

The post holder will require to work in different practices within the area so will require a degree of flexibility and a range of duties that may vary as the service develops.

The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions. An ethos of promotion of independence and partnership-working is integral to this post.

Duties and Responsibilities

Communication and Key Working Relationships

Meetings: Attend MDT for proactive care using Microsoft Team and Steering Group meeting with Clinical Leads and Care Coordinators.

Identification: Support Practices and the PCN OT in Identification of Service Users that need discussion at the MDTs, using criteria agreed as part of the proactive and ageing well projects. BRAVE AI will help to contribute toward finding these cohorts.

Provide background information about individuals for the weekly MDT meetings

Management of Registers: Review service users as required following MDTs using CGA approach; Support updates and development of TEPs and Personalised Care and Support Plans (PCSP); check policies on oral health, nutrition, wound care, falls, continence, and dentition; work with Pharmacists on Structure Medication Reviews (SMRs)

Referral: good awareness of referral pathways when necessary

Admission avoidance and Transfer of Care: Support discharge of patients with Discharge to assess team. Liaise with Somerset Coordination Hub to avoid admissions

Training: support Practices with TEPs (meaningful), CGA, MDT engagement, care pathways e.g., nutrition, falls, catheter

QI: Engage with QI approach as required for measures and outcomes.

Coding: ensure use of correct codes i.e., snomed for QOF

Develop excellent working relationships with all partners, wider service networks including the voluntary sector, adult social care, hospitals, community pharmacists and other members of the MDT

Communicate effectively with service users and their families/carers, and other staff both internal and external and members of the public

Manage and prioritise workload on-a-daily basis and deal with the competing demands of the MDT

Review case load and MDT function. Together collate “Good news” stories

Communicate complex and highly sensitive information which may relate to staff, patients and relatives or commercial undertakings, within and outside the organisation, with the ability to persuade, negotiate and influence others

To help maintain excellent communication, liaison and working arrangement with the PCN, Trust Directorates, NHS England, Somerset Clinical Commissioning Group, Social Services, Voluntary Sector Organisations, Care Homes, and other agencies.

Key Working Relationships Internal:

Clinical Lead for the MDT

Care Coordinators

GPs and General practice teams within the PCN

PCN Clinical Director

PCN Manager

Occupational therapist for PCN

Digital lead

MDT members including but not exhaustive: Clinical Pharmacists, technicians, District Nurses, LARCH Team, OPMH, IRT, Adult Social Care, Paramedics, Social Prescribing Link Workers, Village Agents, Therapy teams.

Key Working Relationships External:

GPs from neighbouring PCNs

Service providers

Social care

Voluntary services

Patients/service users

Carers/relatives

Other proactive care teams in other PCNS

BRAVE AI and ICB digital team

Planning and Organisation

Organise and prioritise workload and work flexibly in response to competing demands.

Support the Occupational therapist with the reporting required and associated within the NHSE DES specifications for required services.

Analytics

IT requirements for recording activity are adhered to in collaboration with other team members

Accurately update clinical GP systems as required.

Provide agreed performance/activity data within the MDT and PCN and to wider organisations as requested

Responsibility for Patient/Client Care, Treatment & Therapy, Including Direct Patient Facing Work

Manage a caseload of patients identified through the MDT and clinical searches

Holistically bring together all of a person’s identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.

Work with practice team/care coordinator/clinical leads on supporting transfers of care (including hospital admissions and discharges) plus out-of-hours calls and present this information to the MDT as required.

Use risk stratification tools to provide information on frequent flyers and service users with high need, working with the Care Coordinator and Clinical Lead

Support the Occupational therapist with new referrals by checking criteria, and where criteria have been met, direct referral to the MDT.

Effectively recognise and manage challenging behaviours in carers and or relatives

Provide information to patients, their carers and/or relatives on behalf of the team

Follow through actions identified by the MDT including carrying out CGA (Complete Geriatric Assessment) arranging tests, referrals, signposting, etc.

Working with the Pharmacists to support person centered Structured Medication Reviews. Working with Service Users and Carers to help communicate changes/adherence.

Policy, Service, Research and Development Responsibility

The post holder will be required to work within clearly defined organisational protocols, policies and procedures

Undertake staff surveys or audits necessary to own work.

Responsibility for Finance, Equipment and Other Resources

Maintain stock control and observe personal duty of care in relation to equipment used in own work.

Observe personal duty of care in relation to equipment used in own work.

Responsibility for Supervision, Leadership and Management

Provide cover for colleagues during periods of absence and leave, as required in the interest of the service.

Is-able-to accommodate change in a rapidly changing environment and encourage team members to embrace necessary adjustments. Has a positive attitude to challenges and their solutions.

Information Resources and Administrative Duties

Attend MDT and Organisational meetings with Clinical Lead and Care Coordinator. Attend Practice meetings to support their work

Maintain strict confidentiality relating to PCN business at all times in particular ensuring that papers and minutes are stored securely (hard copy and electronic).

Use a variety of IT packages including Microsoft Word, Excel, Access, PowerPoint, EMIS and RiO in-order-to complete tasks.

Maintain professional skills and competencies and undertake any necessary skills training, professional updates, and mandatory training as appropriate to the post

Any Other Specific Tasks Required

Act at-all-times in an anti-discriminatory manner

Undertake any training required in-order-to maintain competency including mandatory training

Contribute to, and work within a safe working environment.

Must at-all-times carry out duties and responsibilities with due regard to the GP Practice’s equal opportunity policies and procedures

Is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required

Must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident, or potentially hazardous environment.

Review of this Job Description

This job description is intended as an outline indicator of general areas of activity and will be amended in the light of changing service needs. This job description is to be reviewed in conjunction with the post holder on an annual basis.

General Information

At all times promote and maintain the safety of children by working according the ICB Child Protection Policy and supporting guidance. Being pro-active and responsive to child protection concerns by early reporting, recording and referral of issues according to ICB arrangements. Attending child protection training that is appropriate to your role.

Confidentiality

The post holder will maintain appropriate confidentiality of information relating to commercially sensitive matters in-regard to PCN business, and, also to personal information relating to members of staff and patients. The post holder will be expected to comply with all aspects of the Data Protection Act (1998), the Staff Code of Confidentiality and the IT Security and Acceptable Use Policy.

Taunton Deane West PCN is committed to achieving equality of opportunity for all staff and for those who access services. You must work in accordance with equal opportunity policies/procedures and promote the equality and diversity agenda of the PCN.

Taunton Deane West PCN anticipatory Care Nurse or paramedic Job Description.docv2.doc