ST MARY'S MEDICAL SERVICES

Responsibility

• enable access to personalised care and support
• take referrals for individuals or proactively identify people who could benefit from support through care coordination
• have a positive, empathetic, and responsive conversation with the person and their family and carer about their needs
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• work towards increasing patients’ understanding of how to manage and develop health and wellbeing through offering advice and guidance
• 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
• explore and assist people to access a personal health budget where appropriate
• 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
• work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours
• 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
• support people to take up training and employment, and to access appropriate benefits where eligible, for example, through referral to social prescribing link workers
• identify unpaid carers and help them access services to support them
• support people to develop and implement personalised care and support plans
• 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
• conduct follow-ups on communications from out of hospital and in-patient services
• review and update personalised care and support plans at regular intervals
• work collaboratively with GPs and other primary care professionals to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer to other health professionals
• demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner
• maintain records of referrals and interventions to enable monitoring and evaluation of the service
• raise awareness of how to identify patients who may benefit from shared decision making and support patients to be more prepared to have shared decision-making conversations
• develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them
• miscellaneous
• use tools to measure people’s levels of knowledge, skills, and confidence in managing their health and to tailor support to them accordingly