Working with stakeholders

·       Recognise the relevant key multi-professional stakeholders across the ICS to include, and not limited to, the wider health and social care system.

·       Identify and develop good working relationships with practice staff, private providers, the local primary care team, neighbouring PCNs and other key partners to promote and share best practice.

·       Prioritise and focus on working collaboratively with pharmacy services in other pharmacy sectors such as community pharmacy, medicines optimisation, secondary care, and mental health trust.

·       Develop networks with local, regional, and national interest groups where possible.

Communications and Key Working Relationships

·       Create and maintain constructive relationships with a range of stakeholders, internally and externally including health, voluntary, social, financial and education sectors.

·       Work collectively with local partners and agencies; maintain database and oversight of available services to ensure a sustainable offering for patients.

·       Attend local and national personalised care meetings to provide feedback on local roles and understand national initiatives.

·       Participate and engage with stakeholders across the PCN, providing input and guidance to neighbourhood initiatives where applicable.

·       Liaise, communicate effectively, and collaborate with member practices within the PCNs to ensure smooth running of Personalised Care Teams and their outputs.

·       Communicate effectively with outside agencies sharing appropriate, relevant information to support best practice for ongoing patient care.

·       Leading on community engagement initiatives

·       Maintain comprehensive documentation and records according to legal and local requirements.  This includes recording all relevant information in the patients record and communicating in writing with other health care professionals.

Education and

training

·       Provide training/education sessions to practice healthcare professionals and administration staff including Practice Managers, Social Prescribers and Care Coordinators within the PCN.

·       Provide education to patients and their families on available healthcare options, resources, and self-management strategies.

·       Foster self-empowerment by promoting health literacy and encouraging active participation in care decisions.

·       Offer emotional support to teams, patients, and families throughout their healthcare journey.

Leading Assessment and Care Planning

·       Supporting teams to conduct comprehensive assessments of patients' physical, emotional, and social needs.

·       Collaborate with healthcare professionals to identify personalised care goals and objectives.

·       Lead teams to develop individualised care plans that prioritise patient preferences, values, and cultural considerations

Patient Advocacy

·       Serve as lead advocate for patients, ensuring their voices are heard in the care planning process.

·       Empower patients to actively participate in decisions related to their healthcare.

·       Address and resolve any PCN-wide barriers to accessing personalised care

·       Lead and develop patient feedback methodologies and subsequent action plans

·       Support and implementation of NHS Digital plans to widen participation processes in feedback activities

Coordination of Care

·       Facilitate communication and collaboration between PCN Teams, healthcare providers, social services, and community resources.

·       Ensure seamless transitions of care by coordinating services and support across the healthcare continuum.

·       Monitor and evaluate the effectiveness of care plans, adjusting as needed based on patient progress and feedback

·       Lead safeguarding processes and initiatives

Equality and

diversity

·       Support a culture that promotes equality and values diversity.

·       Support the creation of services that meets the needs of all people and communities avoiding unlawful discriminatory behaviour and actions.

Documentation and Reporting

·       Maintain accurate and up-to-date records of patient assessments, care plans, and interventions.

·       Generate regular reports on patient outcomes, identifying areas for improvement and implementing necessary changes

·       Monitor and audit team documentation on various IT packages

·       Support PCN-specific projects and update progress against objectives

·       Provide regular updates on Personalised Care Team activity and performance

Quality Improvement

·       Participate in quality improvement initiatives, leading insights to enhance the delivery of personalised care across all personalised care disciplines

·       Stay informed about current trends and best practices in personalised care management