Primary Care Nurse Care Coordinator

Job Summary
The Primary Care Nurse Navigator takes a proactive and co-ordinated approach in identifying the most complex and vulnerable people and then co-ordinating and managing their care in partnership with the individual their families and carers. The post holder will also deliver care and support to patients with life limiting illnesses requiring Palliative care, this will involve the delivery of end of life discussions and advanced care planning.

Main Duties of the Job
To support the assessment and development of a personal care plan developed jointly with the patient, carers, relatives and GPs based on assessment of care needs. Ensuring all new patients have care plans within the 21 day target and update and/or amend care plans due to death or relocation.

To be the primary contact for patients in coordinating their care across primary, secondary and community health care as well as social and mental health care. To identify and ensure timely onward referral of patients, as necessary to appropriate Health and Social Care Services identified from assessment.

To support the wider practice team in delivering services for our Housebound patients such as Vaccinations and Annual Reviews.

Organisation and coordination of regular meetings at practice level such as the monthly Palliative Care meetings.

For an informal chat please contact the surgery on View phone number on meeveem.com and ask to speak to Josie Walsh, Practice Nurse or Oonagh Potts, Lead Nurse Practitioner

About Us
Come and join our high achieving very friendly GP training practice. Supported by 2 GP partners, 2 Salaried GPs, 3 highly skilled and experienced Nurse practitioners, 1 Advanced Practitioner, 1 Practice nurse, 2 HCAs and in-house Practice pharmacist and Prescribing technician, along with our very experienced and supportive admin and reception team.

Job Responsibilities

• Supporting the assessment and development of a personal care plan developed jointly with the patient, carers, relatives and GPs based on assessment of care needs.
• Facilitate and support the GPs in case managing patients discharge from hospital by supporting the community team and as appropriate coordinating care and services to be delivered within community to support independence.
• Using an auditing system to monitor the impact of the service quality of care and cost effectiveness.
• To be the primary contact for patients in coordinating their care across primary, secondary and community health care as well as social and mental health care.
• To facilitate the reduction and/or prevention of inappropriate hospital admissions by joint working with all stakeholders.
• To identify and ensure timely onward referral of patients, as necessary to appropriate Health and Social Care Services identified from assessment.
• Coordinate services with hospital, rapid response, OT, Physical therapy, Speech and Language, stroke team, heart failure nurse, COPD, CPN, diabetes and nursing homes
• Monitor daily admissions and discharges particularly those in the target population
• Identification of patients by using Risk Stratification tool and other appropriate data
• Ensure all new patients have care plans within the 21 day target and update and/or amend care plans due to death or relocation
• Organise and coordinate regular meetings at practice level such as the monthly Palliative Care meeting
• Investigate patterns of need, admissions and potential new patients
• To support the wider practice team in delivering services for our Housebound patients such as Vaccinations and Annual Reviews.

Key Working Relationships

• Patients and Carers
• GPs and other practitioners with a special interest
• Local General District hospitals and community hospitals
• Community Geriatrician
• Community Matron and District nurses
• Social workers and Social Care
• Voluntary services
• Networking managers and administrators
• Care/residential nursing homes
• Housing services
• Pharmacys

Skills

• High degree of organisation and an effective time management
• Effective and professional communication skills
• Patient service experience required in a medical environment
• Ability to work effectively within a multi-disciplinary teams
• IT competencies including database use, Word and excel, with some project management skills and a knowledge of clinical software packages
• In depth knowledge of medical practices, treatments, procedures and plans.
• Committed to patient care and able to empathise with a wide variety of patients

Special Requirements for the Post

• An ability to use own judgement, resourcefulness, common sense and local knowledge, to respond to patients enquiries and requests while adhering to practice limitations
• An understanding and acceptance of ones capabilities and awareness of own limitations
• Ability to work without direct supervision and determine own workload priorities
• Basic keyboard and computer skills
• Ability to deal with complex and difficult emotional situations
• Attend and deliver Palliative Care meetings
• Flexibility of working hours
• Excellent communication skills

Physical Skills
To be able to cope with frequent interruptions during work, being able to multi-task. To cope with interruptions form phone calls and queries for impromptu advice, prioritising appropriately

To be able to cope physically and mentally with a daily patient caseload

To comply with practice infection control procedure

To comply with lone working policy

To be able to cope with the emotional stress of supporting patients and at times their distressed relatives

Mental Effort
To work in an environment where there are frequent disruptions to work patterns due to demands from GPs, patients, carers and other staff including responding to phone calls

Emotional Effort
To be involved with difficult discussions with patients and their carers regarding care

To frequently be involved in challenging discussions about patients behaviours and health beliefs that may impact on their own outcomes now or in the future

Working Conditions
Based within the Practice but will be required to visit patients in their own homes

Occasional exposure to verbal and/or physical aggression

Qualifications
Essential

• Registered General Nurse

Desirable

• Evidence of continued professional development

Experience
Essential

• 3 years post registration experience in NHS
• Minimum I.T skills
• Effective and professional communications skills
• Experience of working in Primary Care
• Clinical
• Experience of working in palliative care
• Understanding of GSF in Palliative Care
• Good understanding of EPaCCs
• Knowledge of chronic disease management
• ECGs
• Immunisations & vaccinations
• Venepuncture
• Blood pressure monitoring
• Knowledge of medical practices, treatments procedures and plans

Desirable

• IT skills in clinical programmes

Other
Essential

• Excellent attention to detail
• Flexibility
• Good organisational skills
• Able to work under pressure & manage conflicting demands
• Appearance smart and tidy
• Courteous and pleasant manner
• Good attendance and time keeping
• Good sense of humour

Specialist Knowledge
Essential

• General
• Good standard of spoken and written English
• Good understanding of Data Protection, Caldicott, Gillick Competency and Fraser guidelines
• Clinical
• Knowledge & awareness of own professional limits

Desirable

• Emis Web clinical software
• Microsoft Teams

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.
Applicants must have current UK professional registration. For further information please see NHS Careers website.