Care Home Frailty Health Coach
- Liaises and communicates with each care home linked with Tame Valley Practices
- Develops personal management plans for patients and uses decision making tools for their care
- Liaises between the home and GP Practice to co-ordinate weekly ward round lists, urgent visit requests, and medication requests outside of the ward round times
- Works with Multi-Disciplinary Team (MDT) members to organise direct referrals to their services where beneficial to the patient
- Co-ordinates Stockport Pharmacist (SIPS) team/medicines optimisation in Care Homes and co-ordinates Structured Medication Reviews (SMR) to be carried out for patients.
- Assists with validation of and communication with people registered under a lasting power of attorney
Staff Member: Eleanor McCabe
Frailty and End of Life Health Coach
- Liaises between patients, carers and GPs.
- Develops personal management plans and uses decision-making tools for their care.
- Reviews frailty registers, identifying patients that should be on the end-of-life pathway to ensure they are receiving the care they need.
- Assists with validation of and communication with people registered under a lasting power of attorney.
- Arranges, chairs, and minutes Gold Standard Framework (GSF) meetings. These are multi-disciplinary team meetings for healthcare professionals involved with individuals who require specialist care towards end of life.
Staff Member: Cheryl Wilson
Frailty and Dementia Health Coach
- Liaises between patients, carers and GPs.
- Carries out Dementia reviews and develops personal management plans for patients.
- Carries out Dementia assessments for high-risk patients
- Assists with validation of and communication with people registered under a lasting power of attorney.
Staff Members: Louise Breen