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Job description

HOLMES CHAPEL HEALTH CENTRE

London Road, Holmes Chapel, Cheshire, CW4 7BB
Tel: (01477) 533100 Fax: (01477) 532563Dr Stephen R Tate Dr Robert A F Thorburn Dr Clare J Taylor Dr Nicola Hulme Dr Dinesh Bailoor
Salaried GP – Dr Lydia Wilson, Dr Thomas Dougherty, Dr Georgina Washbrook Practice Manager - Paul Carroll

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Job Description

Job Title:

Proactive Care Administrator

Reports To:

Deputy Practice Manager

Hours:

20 hours / week

Job summary:

• To facilitate and promote health, wellbeing and proactive care of vulnerable and at risk patients registered at the Holmes Chapel Health Centre.
• To act as a central point of contact, coordination and facilitation for allied health and social care practitioners / providers.

Job responsibilities:

• To coordinate and maintain the list of patients identified as requiring proactive care and palliative care by the GP Practice.
• To liaise with patients identified as requiring proactive and palliative care in order to:
• Provide health and wellbeing support and signposting to appropriate support services.
• Facilitate the maintenance of patient care plans.
• Ensure continuity of care following discharge from hospital.

• To be the primary communication link between primary and secondary care in respect of those patients identified as requiring proactive care who experience an unplanned hospital admission.
• To liaise with other health and social care providers (such as Social Services, District Nurses, Community Matrons, Mental Health Professionals) as required, to facilitate proactive and palliative care for the patients.
• To act as the central administrator, coordinator and facilitator for the Congleton and Holmes Chapel Neighbourhood Team.
• To develop and maintain electronic information sharing systems.
• To receive, collate and coordinate information from hospital admissions and discharges for all patients identified as requiring proactive care.
• To receive, collate and coordinate information from A&E attendances and emergency admissions for all patients identified as requiring proactive care.
• To produce a monthly information pack for practice GPs to review appropriateness of hospital admissions and to identify whether anything could have been done to avoid the hospital admission and/or A&E attendance.
• To provide “Welcome home” calls to patients following admission to hospital within the agreed three day post discharge period.
• To gather information for team members regarding patients for review at the practice Multidisciplinary Team (MDT) meetings.
• To ensure all recorded information is accurate, up to date and factual.
• To work with team colleagues in the support and on-going development and improvement of systems and processes.
• To undertake surveys and audits as required.
• To support with the analysis and compilation of stats to support the on-going evaluation and success of the service.
• To work within clearly defined organisational protocols, policies and procedures.

Confidentiality:

• In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.
• In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential.
• Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Indemnity:

The post-holder will be provided with suitable medical indemnity to undertake the role.

Health & Safety:

The post-holder will assist in promoting and maintaining their own and others’ health, safety and security as defined in the practice health & safety policy, the practice health & safety manual, and the practice infection control policy and published procedures. This will include:

• Using personal security systems within the workplace according to practice guidelines.
• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks.
• Making effective use of training to update knowledge and skills.
• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.
• Actively reporting of health and safety hazards and infection hazards immediately when recognised.
• Keeping own work areas and general / patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holder’s role.
• Undertaking periodic infection control training (minimum annually).
• Reporting potential risks identified.

Equality and diversity:

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

• Acting in a way that recognizes the importance of people’s rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation.
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
• Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

Personal/professional development:

The post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include:

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

Quality:

The post-holder will strive to maintain quality within the practice, and will:

• Alert other team members to issues of quality and risk.
• Assess own performance and take accountability for own actions, either directly or under supervision.
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team’s performance.
• Work effectively with individuals in other agencies to meet patient’s needs.
• Effectively manage own time, workload and resources.

Communication:

The post-holder should recognize the importance of effective communication within the team and will strive to:

• Communicate effectively with other team members.
• Communicate effectively with patients and carers.
• Recognise people’s needs for alternative methods of communication and respond accordingly.

Contribution to the implementation of services:

The post-holder will:

• Apply practice policies, standards and guidance.
• Discuss with other members of the team how the policies, standards and guidelines will affect own work.
• Participate in audit where appropriate.

Willingness to travel:

The post-holder will be willing to travel locally as required in order to facilitate local Congleton and Holmes Chapel Peer Group meetings.

Tasks List updated April 2023:

Proactive Care – Current Job Description

Presently 20 hours over 3 days

To also incorporate safeguarding register administration.

To use Emis Web to identify top 5% most vulnerable patients and ensure all have appropriate care plans in place.

Attend MDT meetings as required.

Invite attendees and lead on Palliative Care meetings.

• Liaise with Social Services over email – create referrals to them
• Call Rapid Response Team when necessary
• Refer to Physio and Occupational Therapy – discuss waiting times
• Refer to Continence Team if appropriate
• Refer to Carer’s Hub if Carer needs support, signposting assessments
• Refer to Bereavement Support
• Refer to Community Support
• Refer to Talking Therapies
• Refer to SPCT – check hospice and home referral done if appropriate
• Palliative OT and Physio input
• Benefits can claim at EOL ie Attendance Allowance DS1500
• Need CHC – contact relevant clinician
• Support on phone to families/patient
• Refer to DN if needed

• Letter to patient if cannot get hold of them asking them to contact HCHC
• NWAS and Out Of Hours
• NWAS – set up patient on ERISS and update expiring alerts
• OOH’s – send referral via email and let them know EOL
• New UDNACPR status – update EMIS

• If patient prognosis is 12 months or less commence EPACCS template (GSF), EOL Register and Palliative codes
• Refer to Dietician
• Refer to Snow Angels – Financial Help
• Refer to Mental Health Reablement
• Update Proactive Care Plans
• Create Proactive Care Plans
• Update Admission Avoidance Care Plans
• Refer to in house Physio
• Refer to Speech And Language Therapy
• Refer to ‘Healthier You’ programme
• Refer to NHS Podiatry if eligible
• Receive discharge summaries
• Call patient on a proactive courtesy call to see how they are doing
• Check if anything is needed
• Task and refer as appropriate

• Send information to patients about relevant services
• Ask reception to book appointments for patients
• Code Care Plans
• Deal with incoming calls
• Outside services
• Patients
• Relatives
• Direct phone number given to some patients/family members

• Refer to Wheelchair Service
• Falls Prevention Work
• Admiral Nurse referral – if patient is on GSF and consent to this support
• Respond to all tasks, emails and screen messages
• Referral to Dementia Reablement
• Dementia support
• Help with day centres

• Refer to Rosscare for pendant alarm
• Equipment management.
• Liaise with McMillan Nurses
• Liaise with Parkinson Nurses
• Support patients living with these conditions
• Help patients and families source care provision, liaise with SS and private care agencies
• Refer to ‘Take a Breath’ service in Congleton
• Refer to Stroke Rehab
• Advocacy support
• Safeguarding – liaise with MDT
• Attend MDT meetings on MS Teams – discuss HCHC patients
• Liaise with GP or other MDT

• Chase clinic letters when requested
• Call nominated pharmacies when requested
• Call patient when social care needs identified by GP
• Avoid readmission to hospital
• Follow it through, call patient, give PCA number – support
• Urgent tasks – respond accordingly – call and see what the issue is ASAP
• Liaise with SPLW about patients
• Code housebound patients
• Discuss pain with patients – do they need a pain review
• Discuss pressure relief – pressure sores – is a DN appropriate
• Refer as needed

• Provide support to relative when patient has gone into a nursing home
• Talk to care agencies about patients needs to plan the package of care (if private)

• Liaise with Communicare and introduce patients to the scheme
• Discussion around NOMAD packs and medication delivery
• Monitor nursing home patient and attempt to update EOL EPACCS if not completed
• Give relevant contact numbers to patients and staff.

Job Type: Part-time
Part-time hours: 20 per week

Salary: From £11.00 per hour

Benefits:

• Free parking

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Crewe: reliably commute or plan to relocate before starting work (required)

Work Location: In person

Application deadline: 14/04/2023
Reference ID: Holmes Chapel Health Centre- Pro-active care administrator (part time role)