Care Coordinator (Frailty)

· Assessing and coordinating patients and collaborating with other health and social care professional as well as the voluntary sector. · Understanding the needs of Frail patients and ensuring their needs are met that are based on clinical and presenting problems that ensure high quality patient outcomes that support individuals, families and carers., · To co-ordinate the pathway of care for vulnerable older people, identified for case coordination across all service interfaces. This will involve managing a varied caseload and working with and across agencies · To actively engage and have a regular presence with the GP surgeries and PCN's, supporting them with proactive identification of patients, frail and at risk of admission/loss of independence · To be an active participant at monthly GP/PCN MDT's highlighting patients in anticipation of triggers or perceived crisis, ensuring a proactive plan is in place earlier rather than later · To actively track patients going into hospital known to the team, forge strong links with secondary care, and follow the patient's home on discharge · Within discharge to assess /visit clients at home within 2 days of hospital discharge, conducting a holistic assessment of their physical, social and psychological needs · To ensure that the patient has an individual care plan with focused goals central to the care coordination process. · To support the use of frailty tools and risk assessment tools across the wider teams. · To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carer's families, and colleagues. EPUT are looking for motivated staff who shares our Trust values of Care, Learn and Empower. In return, EPUT can offer you a range of benefits and development including;

• Season Ticket Loans
• NHS discounts for staff
• Excellent Training facilities and opportunities
• Buying and Selling annual leave scheme
• The opportunity to work bank shifts and expand knowledge and experience in other areas
• Salary Sacrifice schemes including lease cars and Cycle to Work
• Day One Flexible Employer
The Trust supports and actively encourages flexible working for all employees. We offer many options and you are encouraged to ask the recruiting manager what is possible for this role. If appointed, you will have the opportunity to apply for a flexible working request from the first day of your employment Join our Staff bank What is Staff Bank? Our EPUT NHS staff bank is an entity managed by the trust that hires clinical and non-clinical healthcare professionals to take on shifts at our trust hospitals and community settings. Here at EPUT we maintain our own bank of specialist staff to ensure that we are able offer safe and effective care at all times. All our permanent staff are automatically enrolled onto the staff bank however this does not mean you have to work any additional shifts, but the option is there for you if you wish. If you are joining our Trust in a fixed term role, please indicate on your New Starter Paperwork that you wish to join our staff bank. · To refer the client to other services as required. · To ensure that the client is accessing all the benefits to which they are entitled, helping to access advice where needed. This may involve the engagement of the voluntary sector for this function · To provide informal support and advice to older people and their carers about the social, health and voluntary services available to them. · The post holder will demonstrate flexibility and adaptability to manage risk in order to work safely in different environments · To effectively communicate any decisions made, to all appropriate agencies and negotiate where appropriate and required. · To act as a resource to all levels of staff across all teams, providing support and advice re patient focused goals, and services available to support them, and how best to access them. · To act as a resource to all levels of staff across all teams, providing support and advice re patient focused goals, and services available to support them, and how best to access them. · To feedback to Line Management any problems / gaps in service identified, so that they can be addressed using the collaborative approach. · To work closely with the senior care coordinator to contribute to the development of the care coordination model, as a dynamic, flexible service. · To assume delegated responsibility on specific areas of service development as highlighted by the senior care co-ordinator. · To contribute and input appropriate data into relevant databases · To work independently, adapting skills and knowledge, as well as delegating appropriately to support staff · To assist in the collection of audit data for analysis to help monitor progress made by the team and its effect on the whole system. · To provide health and social care screening to all older people visited · To act as an ambassador of the care coordination model, and help raise the profile of the service · To act as a Trusted Assessor as required i.e. to be trained to assess and commission minor adaptions (such as bath rails) and routine equipment (such as bath seats and kitchen equipment for people with arthritis) and for telecare equipment, to avoid the need for onward referral to other services · The post holder will carry out all duties in accordance with current Quality Assurance systems and procedures and actively contribute to continuous improvement of service delivery through regular feedback in meetings, any Quality Assurance forum and through user feedback. · The post holder will deliver a cost effective model that achieves maximum impact for patients. ADDITIONAL DUTIES In addition to the above duties you will also be expected to perform the below key activities in line with your job role; - Complete mandatory training in line with Trust policy and procedures - To participate in the staff appraisal process and to undertake for any staff you manage - To keep yourself updated on all matters relating to Trust policy - To provide management supervision where appropriate - You will be expected to work collaboratively with key partner organisations, service users, carers, clinicians and other practitioners within the multi-disciplinary team in delivering services; providing a 7-day a week, 24-hours a day service for 365 days a year working shifts, where appropriate and operationally required.