PCN Anticipatory Care Nurse / Paramedic – Taunton Deane West PCN

Taunton Deane West Primary Care Network

Job Title: Taunton Deane West - PCN Anticipatory Care Nurse / Paramedic

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 R Rachel Yates

Pay/Hours

TBC

Fixed Term 12 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

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