Role Purpose: To support the practice in delivering excellent patient care by taking a proactive approach to promoting community.....
Role Purpose: To support the practice in delivering excellent patient care by taking a proactive approach to promoting community health and wellbeing. Health & Wellbeing Coaching Work with GPs and the wider clinical team to identify and manage a caseload of patients likely to benefit from a health and wellbeing coaching Provide reactive support by taking referrals from within the practice and the wider PCN partners for individuals who would benefit from support Provide proactive support by identifying cohorts of patients to work with Take referrals from within the practice and the wider PCN partners for individuals who would benefit from support Work with people focussed on physical, people with long term conditions and those at risk of developing an LTC and mental health conditions. Provide personalised support to individuals, their families, and carers to support them to be active participants in their own healthcare; empowering them to manage their own health and wellbeing and live independently Coach and motivate patients through multiple sessions to identify their needs, set goals, and achieve their personalised health and care plan objectives Provide interventions such as self-management education and peer support Support patients in making choices and positive risk taking while ensuring that they understand the impact of their own actions and decisions, thus encouraging the proactive prevention of further illnesses Work in partnership with other members of the Proactive Care Team and other services to connect patients to community-based activities which support them to take increased control of their health and wellbeing Work with patients to increase their motivation to self-manage and adopt healthy behaviours Make referrals to other healthcare professionals within the Primary Care Network Work with patients with lower activation scores to understand their level of knowledge, skills and confidence (their Activation level), when engaging with their health and well-being and subsequently supporting them in shared decision-making conversations Utilise health coaching skills to support people with lower levels of activation to develop the knowledge, skills, and confidence to manage their health and wellbeing, whilst increasing their ability to access and utilise community support offers Explore and support patient access to a personal health budget, where appropriate, for their care and support. Be able to support people, during various stages such as: Prevention and Staying Well Supporting people to self-manage, increase activation levels and sustain behaviour change. Improve patient outcomes e.g., weight reduction, improved BP, increased activity Deterioration/Acute Episodes Help people develop and implement strategies for the early management of exacerbations and flare ups e.g., managing episodes that may contribute towards poor health Enable confidence to know when to self-care and when to seek medical attention Discharge and Recovery Support people to come to terms with new situation/diagnosis, limitations and change of life. Support people in problem solving and working through strategies towards independence on discharge where appropriate. Support people to become active in management of new conditions Development Activity Actively promote your role and that of the Proactive Care Team within the practice, PCN and beyond Develop and deliver initiatives including group sessions, health improvement activities and health awareness campaigns in practice and out in the community Develop strong links with local health agencies and the voluntary and community sector providers to support patients health and wellbeing. Raise awareness of shared decision-making and support tools within the practice and how to identify patients who may benefit from this approach Use population health data to tackle local inequalities in health and social care Provide education and specialist expertise to PCN staff, supporting them to improve their skills and understanding of personalised care, behavioural approaches and ensure consistency in the follow up of peoples goals Reporting Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact on their health and wellbeing Produce case studies showing the impact of health and wellbeing coaching Work closely with staff across the practice to ensure that the health and wellbeing coaching referral codes are inputted into clinical systems Maintain effective records of activity and produce reports as required Provide agreed performance/activity data This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to take into account development within the Practice. All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the Practice. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.
