The person appointed to this post will work as part of the integrated care programme for older persons to support older adults in accessing the assessment and intervention needed to address increasing health needs while being maintained in their home.
This role will coordinate the day‑to‑day functions of the outreach team and work as part of that team as required.
Key Responsibilities
Rapid access assessment
Rapid access to specialist assessment and treatment pathways (Frailty, Falls, Cognitive pathways)
MDT Comprehensive Geriatric Assessment (CGA)
Access to reablement and rehabilitation after acute illness or injury
Complex case management and care coordination
Promotion and support of population health and wellbeing initiatives with primary care
The post holder will co‑ordinate the day‑to‑day functions of the ambulatory outreach team and work as part of that team as required.
The post holder will ensure that team structures are attended to so that the service is consistent with recognised best practice in team functioning.
While clinical functions are central to the role of liaison, they also perform signposting to ensure a seamless integrated service for older adults.
The post holder will work with staff in Acute Services ICPOP Hubs, Community healthcare networks, and GPs to support the management of older person care needs as close to home as possible and to signpost to the most appropriate specialist clinical service, including in the specialist hubs when required.
The post holder will coordinate with the clinical teams in the hubs, working alongside GPs and Community Healthcare Networks.
They will ensure that the clinical needs of vulnerable older adults are assessed and managed, including in the specialist ambulatory care hub, and support patients in accessing appropriate care pathways promptly, ensuring a seamless continuum of care between primary care and specialist services.
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