Care Co-ordinator

Job description

Job responsibilities

Primary Responsibilities

The following are the proposed core responsibilities of the PCN Patient Care Co-ordinator. These are subject to change dependent on the needs of the business and there may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:

PCN Administration Support

o You will support administratively any tasks set by the Social Prescribers.

o You will support administratively with the Enhanced Frailty Service.

o You will develop new PCN services, in liaison with the Clinical Directors Assistant and Network Services Lead.

o You will assist the Carers Lead in developing carers groups, support and resources.

o You will support with any tasks associated with the PCN or NHSE/CCG initiatives such as CCLIP, Population Health Management or DES activities.

o You will support clinicians and administration staff with group consultations if required.

o You will assist with any additional work as delegated by the Clinical Directors Assistant or Network Services Lead.

Enhanced Health in Care Homes

o You will utilise population health intelligence to proactively identify a cohort of patients to allow health colleagues to deliver personalised care. This may take the form of risk stratification, clinical system searches and information from the CCG Business Intelligence teams.

o You will support administratively clinicians to utilise decision aids to prepare patients for shared decision-making conversations.

o You will support administratively clinicians to bring together a persons identified care and support needs and ensure all patients have a single personalised care support plan in line with best practice, based on what matters to the person.

o You will ensure all identified patients have had a comprehensive assessment and support the identification of these patients, ensuring a robust recall system is in place.

o You will support and work closely with Health & Social Care Coordinators.

o You will help support the identification of care home residents who are likely to die within the next twelve months and prioritise these patients as needing care planning, ensuring that records and plans contain information such as preferred place of death, escalation treatment plans and palliative care medication.

o You will support in the after death analysis of this cohort of patients.

o You will ensure these patients have been seen by a clinician within the appropriate amount to time before death and put in place a robust recall system to ensure the patient is always within the specified date of seeing a clinician before dying, linking with practice staff who administrate any care home ward round.

Administration of the Structured Medication Review

o You will ensure that all identified patients have a Structured Medication Review and support the identification of these patients. This will mean linking with Pharmacy teams, GPs and using an appropriate case finding tool to proactively call and recall this cohort of patients.

o You will support administratively any tasks as set by the Pharmacy team.

o You will act as a liaison between patients, Pharmacy teams and the practice as appropriate.

o You will help administratively with any auditing or searching of GP clinical systems.

Mental Health Reviews

o You will liaise and link with the Mental Health Support Workers to set up a proactive call and recall system for patients on the QOF Mental Health Register, booking them as appropriate for an annual mental health review.

o You will act as a link between the Mental Health Support Worker, the GP and any PCN, primary, community of secondary care colleagues, supporting administratively any onward referrals, care planning or administrative patient needs as appropriate.

QOF QI Domains

On a yearly basis it is usual for QOF (Quality Outcomes Framework) to introduce QI (Quality Improvement) domains and these are likely to change on a yearly basis. Part of this role is to administrate all aspects of these domains and on a yearly basis you should work with the Network Services Lead and/or the Clinical Director to scope out the necessary requirements and embed a system for achieving the points within the domain for the practice.

In 2021/22 the domains are:

Administration of the Early Cancer Diagnosis Requirements

You will support administratively the Early Cancer Diagnoses requirements of the

QOF QI domain including but not limited to;

o supporting any quality improvement auditing and running of searches on the clinical system.

o ensuring patients are signposted or have access to further support, linking them with Social Prescribers, Health Coaches or other specialist Cancer Support Networks.

o proactively improve the uptake of cancer screening such as cervical smears or bowel screening programmes to find innovative, simple and cost effective uptake measures such as texting patients who DNA bowel screening or administrating cancer week initiatives.

o You will link with Patient Participation Groups, Social Prescribers and Practice Supporters to promote cancer screening or awareness events.

o You will help with the administration of any peer reviews, case finding, running of searches and sharing anonymised patient data.

Administration of Supporting People with Learning Disabilities

o Work with the Practice and Learning Disabilities teams to collect a baseline of numbers of patients on the register aged 14+.

o Help support the practice in increasing the reach and uptake of Learning Disabilities Health Checks and communication with Learning Disabilities teams, patients and their carers.

This job description is only a very brief summary of what a Network Care Coordinators job will entail and the role will expand and change over time as the needs of the PCN changes, the requirement of the Network DES expands and the priorities of the population evolve.

Person Specification

Qualifications

Essential

• Educated to GCSE level or equivalent
• GCSE Mathematics & English (C or above)

Personal Qualities

Essential

• Eager and willing to learn and develop new skills
• Ability to problem solve and work autonomously
• Polite and confident
• Flexible and cooperative
• Motivated
• Forward thinker
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure

Desirable

• Experience of working in a health care setting
• SystmOne user skills
• Administrative experience

Experience

Essential

• Experience of working with the general public
• Experience of administrative duties
• Excellent communication skills (written and oral)
• Strong IT skills
• Clear, polite telephone manner
• Competent in the use of Office and Outlook
• Effective time management (Planning & Organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving & analytical skills
• Ability to follow policy and procedure

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

Employer details

Employer name

Gillingham Medical Practice

Address

Barn Surgery

Newbury

Gillingham

Dorset

SP8 4XS

Employer's website

https://www.gillinghamsurgery.co.uk/ (Opens in a new tab)