PANACEA COLLABORATIVE

Responsibility

• support the coordination and delivery of multidisciplinary teams with the PCN
• key responsibilities Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes
• help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care
  Show more +12
• assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health
• explore and assist people to access a personal health budget where appropriate
• support people to take up training and employment, and to access appropriate benefits where eligible; for example, through referral to social prescribing link workers
• provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support
• enable access to personalised care and support a
• work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN
• take referrals for individuals or proactively identify people who could benefit from support through care coordination; b
• have a positive, empathetic and responsive conversation with the person and their family and carer about their needs; c
• raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations
• work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance; d
• work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours; Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies; Conduct follow-ups on communications from out of hospital and in-patient services; Maintain records of referrals and interventions to enable monitoring and evaluation of the service; Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances; Contribute to risk and impact assessments, monitoring and evaluations of the service; Key Tasks 1
• f