Liver Health Checks and HCC Surveillance Pathway NavigatorinDartfordinDartfordPUBLISHED WED 27 NOV 2024

The post holder will communicate with the multi-disciplinary team (MDT), acting as a specialist resource, demonstrating advanced verbal and non-verbal communication skills with patients, carers and medical and non-medical staff, ensuring communication is at a level appropriate to individual understanding.

They will communicate information that is complex and sensitive pertaining to patients with diagnosed or suspected liver cancer.

The Pathway Navigator will work as part of a multi professional team to deliver the Liver Health Checks and Liver Surveillance programme.

They will support the patient journey by providing a single point of access, including rapid re-entry into the system for those people identified as having urgent or specialist needs.

Key deliverables include working to facilitate a smooth patient journey ensuring that co-ordinated and streamlined administrative processes revolve around patients identified as eligible for cancer surveillance following a screening fibro scan in Liver Health Checks clinics across the network.

The post holder will have administrative responsibilities including data management and patient tracking for those individuals participating in the liver health checks programme including patients referred into hospital-based liver cancer surveillance clinics.

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Specific Responsibilities:

Administrative Management

1.1 Support scheduling of Liver Health Checks clinics across the ODN including primary and secondary care, substance misuse services and mobile van-based clinics

1.2 Co-ordinate patient referrals from the community Liver Health Checks CNS to the Hepatology service and radiology department at the Trust and at network providers and administer in line with timings and requirements as set out in the pilot Surveillance pathway

1.3 Co-ordinate and provide administrative support to the clinical teams (and their secretarial staff) to ensure all relevant paperwork and clinical information is available for consultations

1.4 Maintain and populate the Patient Tracking list for the Liver Health Checks clinics and HCC Surveillance Tracker for the people engaged with the pilot across the ODN

1.5 Identify from the Tracking list the next steps in the patients surveillance pathway in line with target surveillance dates and or clinical need (Peer review)

1.6 Develop an understanding of the milestones within the Liver Cancer surveillance pathway and relevant national guidance (e.g., NICE)

1.7 Update all enquiries regarding patients liver condition and treatment on the liver surveillance pathway, including all diagnostic testing and various other medically required tests from the patients GP in a timely manner

1.8 Triage incoming calls, using a risk assessment framework and initiate appropriate response according to protocols and individual pathways, using good communication skills, basic clinical awareness and appropriate tools and procedures, liaising as appropriate when non-routine and refer clinical decisions to the team for assessment and review.

1.9 Provide basic telephone advice regarding appointments and test schedules and refer on or signpost to other sources of support (e.g., the British Liver Trust)

1.10 Coordinate the necessary assessments, appointments, or investigations to fast-track people with abnormal results (suspected HCC) in the surveillance programme into the Cancer TWR pathway.

1.11 Make pre planned outbound telephone calls to patients to remind patients of upcoming surveillance scans / laboratory diagnostics, and identify and assist in resolving any barriers to engagement (e.g., booking linked phlebotomy appointments for patients attending for surveillance USS)

1.12 Co-ordinate text reminders for surveillance appointments for patients across the ODN

1.13 Support information delivery. This role may include printing out or emailing patient information, assisting people accessing relevant web-based information or signposting to support services

1.14 Develop and maintain a Patient tracking list for standard of care (non-pilot) patients already engaged with HCC surveillance

1.15 Encourage and support active and healthy lifestyle choices

1.16 Monitor patients on surveillance pathways and proactively find resolutions to improve adherence to target surveillance dates. E.g., tracking attendance and DNAs and escalation of patients overdue surveillance to the Program manager and clinical teams.

1.17 Work with the Hepatology CNS and lay peer support workers to maintain engagement in the surveillance pathway and to reengage patients with surveillance following a DNA.

1.18 Identify indicators of need or changes in need through telephone contact and respond appropriately

1.19 Identify and proactively find resolutions to barriers to care. Where necessary this may include signposting to social care support or support to access travel costs for individual patients.

1.20 Ensure timely and efficient transfer of patient information between trusts / clinical teams involved in the patients pathway particularly those recently diagnosed with cirrhosis through the ODN.

1.21 Track surveillance results and co-ordinate face to face appointments for those with abnormal test results from surveillance investigations within a TWR timeframe

1.22 Work in a multidisciplinary team in developing the Liver Health Checks and Cancer Surveillance pilot in line with the department hospital and Cancer Alliance plans

1.23 Ensure all health records are appropriately tracked and securely stored in accordance with the health records policy

1.24 Identify and suggest improvements that can be made to patient care pathway and or the patient pathway tracking process

1.25 Track the onward management of any suspected cancer patients diagnosed through the pilot and share relevant data with the designated Cancer pathway co-ordinator

1.26 Plan the outreach activity associated with the service, ensuring the appropriate resource is available

1.27 Escalate any issues and breaches of the waiting times standards to relevant management in line with agreed escalation processes

1.28 Diary management and preparation of urgent clinical correspondence for the CNS team and Lead clinician

1.29 Responsible for maintaining appropriate levels of stock required for the service to run efficiently

1.30 Collate and update patient information on the relevant databases in line with local policy,

1.31 Review and support development of Standard Operating Procedures and ODN targets

Data Collection and Analysis

2.1 Work with the operational team and clinical team to analyse target surveillance breaches and report issues to the ODN management team

2.2 Document and monitor aspects of care coordination and service delivery for audit and report to the ODN management team Cancer Alliance and NHS E&I Cancer Program board

2.3 Support and contribute to audit processes, governance, research, clinical research trials and service development

Training and Development

3.1 All budget holders will undertake on the job training in all matters financial and will be responsible for ensuring they are setup in the finance/procurement/HR systems with the appropriate authorisation levels.

3.2 Undertake annual review and statutory and mandatory training

3.3 Keep portfolio

3.4 Ensure attendance at department training sessions as required for professional/personal/service development