Ageing Well Care Coordinator

Wimborne and Ferndown PCN are looking for an Ageing Well Care Coordinator to join our team, supporting the Ageing Well Nurse and Practice teams. This role will be for up to 15 hours per week.
The role of the Ageing Well CareCoordinator looks to support the elements of the Network DES and the AgeingWell Programme is a mixture of administration, project management and carecoordination, supporting teams and practices in delivering the key performanceindicators of the Enhanced Health in Care Homes and Ageing Well programmes.More information can be found on the following link:
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This role will support the practicecare home teams, the care homes and the patients residing in them. Of course,not all older people are residents in a care home, and some will be living athome, either independently or with assistance from unpaid, or paid carers.
Main duties of the job Work through the elements of theproject plans, aligning practice-based work with PCN and national directives. Ensure key deliverables areon-track, managed and provided to patients. Be the champion across the Networkfor the Ageing Well and Care Home projects. Follow our system to ensure that allcurrent and new care home residents and frail patients have a care plan in place that is updatedregularly by appropriate individuals. Work with Care Homes to ensure thatthey have patients linked to online access (with patient consent.) Work with care homes to ensure they fully understand the technology available to them to support the delivery of care to their residents. Ensure that Structured MedicationReviews for Care Home patients are on target. Monitor the key deliverables toensure that practices and the Network achieve any targets via the QualityOutcome Framework, Impact and Investment fund, the Network DES etc. Work with the Care Coordinator Team to target unwarranted health outcomes and using the local infrastructure (suchas the Social Prescriber) to improve the health of the targeted populationusing recognised Population Health Management tools (such as the DiiS orElectronic Frailty register.). Provide administration support to our Ageing Well Nurse and Paramedic team About us Wimborne & Ferndown PCN provides services to 42,000patients across 4 Practices (Quarter Jack Surgery, Walford MillMedical Centre, Pennys Hill Practice, Orchid House Surgery). We have adoptednew roles within the PCN to support and broaden our primary care team whichallows us to provide better care for our patients.
The PCN is headed by our committed Clinical Directors and a PCNManager. We also have an Admin team who support theoverall network team and services.
In addition to the PCN, our Practices are also part ofCastleman Healthcare, a non-profit company owned by 13 GP Practices in NorthPoole and East Dorset (3 PCNs). Castleman Healthcare offer additional servicesto our Patients through separate contracting arrangements, provide business andpractical support to the PCNs and support with representing the PCNs voicewithin the wider healthcare system.
Job responsibilities Withthe creation of the 2020/21 Network Direct Enhanced Service (DES) and theintroduction of the NHS Additional Role Reimbursement scheme for new primarycare roles, an opportunity has arisen for Primary Care Networks (PCNs) to bringin roles that support GP practices, Networks and elements of the Network DESand this role looks to support this work administratively, linking the PCN andpractices with the wider health care community, including but not limited toMDTs, social care, community care, pharmacy teams and care homes.
AdditionallyNHS England have introduced, as part of the NHS Long Term Plan a nationalAgeing Well Programme.
People in England can nowexpect to live for far longer than ever before but these extra years of lifeare not always spent in good health, with many people developing conditionsthat reduce their independence and quality of life. TheNHS has a key role to play in helping older people manage these long-termconditions, making sure they receive the right kind of support to help themlive as well as possible.
TheNHS Long Term Plan will give them greater control over the care they receive,with more care and support being offered in or close to peoples homes, ratherthan in hospital.
Wewill also make better use of technology such as wearable devices and monitorsto support people with long term health problems in new ways, helping them tostay well and live independently for longer.
Therole of the Ageing Well Care Coordinator looks to support the elements of theNetwork DES and the Ageing Well Programme is a mixture of administration,project management and care coordination, supporting teams and practices indelivering the key performance indicators of the Enhanced Health in Care Homesand Ageing Well programmes. More information can be found on the followinglink:
And
Thisrole will support the practice care home teams, the care homes and the patientsresiding in them. Of course, not all older people are residents in a care home,and some will be living at home, either independently or with assistance fromunpaid, or paid carers.
Tomethodically action the elements of the project plan against nationally setcriteria including but not limited to:
Support the Ageing Welland Enhanced Health in Care Homes Project Plans Workthrough the elements of the project plans, aligning practice-based work withPCN and national directives.
Ensurekey deliverables are on-track, managed and provided to patients.
Bethe champion across the Network for the Ageing Well and Care Home projects.
Linkpractices, patients, the Network, community and hospital services together bybeing the conduit to the Network and the practices.
Urgent Community Response Bethe link between the Network and the community provider.
Personalised Care andSupport Plans Follow our system to ensurethat all current and new care homeresidents have a care plan in place that is updated regularly by appropriateindividuals such as GPs, ANPs, Nurses, community teams, care home staff.
Assessthe need for care plans to be put in place in the wider community for thosepatients living outside of care homes.
Help professionals, caresand individuals navigate the health and care system Bethe first port of call for queries and problems relating to the navigation ofsystems. Help guide, direct and support patients and their carers.
Palliative and end of lifecare Designand instigate a robust system of ensuring palliative patients are raised by thepractice, discussed and MDT. Ensure patients are on the Gold StandardFramework, ensure care plans are in place shared appropriately. Ensure carehomes can access palliative care support. Set up training sessions for carehome staff to support their palliative patients.
Mental health and DementiaCare Ensurecare plans have appropriate mental health sections within them. Research DiADEMand DEAR-GP as a means to support patients with dementia.
Falls Prevention Helpto administrate any falls prevention schemes.
Technology and Data. Supportcare homes and practices in the use of setting up dedicated, monitored carehome NHS mail accounts.
Workwith Care Homes to ensure that they have patients linked to online access (withpatient consent.)
Workwith care homes to ensure they fully understand the technology available tothem to support the delivery of care to their residents.
Ensurethat Structured Medication Reviews for Care Home patients are on target.
Monitorthe key deliverables to ensure that practices and the Network achieve anytargets via the Quality Outcome Framework, Impact and Investment fund, theNetwork DES etc.
Workwith the Care Coordinator Team to target unwarranted health outcomes and usingthe local infrastructure (such as the Social Prescriber) to improve the healthof the targeted population using recognised Population Health Management tools(such as the DiiS or Electronic Frailty register.).
Workwith Network leads to help administrate any MSK, CVD, Dementia and Frailtyneeds or services.
Person Specification Experience Experience and/or knowledge of the NHS and Care Homes. Data management and analysis skills. Awareness of confidentiality and ability to deal appropriately with sensitive or difficult situations. Ability to act as a role model demonstrating effective behaviour and leading by example. Ability to manage various projects in a timely manner. Flexible, versatile, and self-motivated. Ability to work as part of a team or on own projects Open minded and positive, focused on solutions not problems, a can do attitude. Flexible working attitude Be a strategic thinker with an ability to be innovative Experience of working in a health and social care environment. Practical experience of managing change. SystmOne knowledge Qualifications GCSE grade A to C in English and Maths Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
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