Clinical Care-Coordinator

Job description

Job responsibilities

Develop and review personalised care and support plans with patients, their families, and carers to better manage their needs and achieve improved healthcare outcomes. Collaborate with patients, their families, and carers to increase everyone's understanding of the patient's condition.

Help people manage their health conditions through undertaking routine screening and annual clinical reviews.

Refer patients to the wellbeing team to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health

Key tasks

You will be trained to carry out tasks such as phlebotomy, blood pressure monitoring, NHS Healthchecks, Urinalysis, and chaperoning to help support the GPs and Nurses, and prepare patients for their annual long term condition reviews

Working towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance

Work with the wider PCN, surgery staff, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register,

Maintain a professional attitude to patients and display a caring, positive attitude at all times

Work strictly within guidelines and policies which are set

Coordinate and Integrate Care

Refer onwards to social prescribing link workers and health and wellbeing coaches where required

Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported, by participating in multidisciplinary team meetings at the Surgery and in the PCN as and when appropriate

Monitor and review Practice performance of the IIF indicators and target cohorts

Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns

Information accuracy, storage and transmitting

Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation

Work sensitively with people, their families and carers to capture key information, while tracking the impact of care coordination on their health and wellbeing

Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.

Professional Development

You will be working alongside the wider team, to gain advice and support. Undertaking continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities.

You will need to adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality & diversity and health & safety

It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by the Practice Manager or PCN Manager to this role. This list of duties is not intended to be exhaustive, but indicates the main areas of work and may be subject to change after consultation with the post holder to meet the evolving needs of the Service.

Person Specification

Skills and Knowledge

Essential

• Good IT skills - understanding of Microsoft Office.
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Ability to recognise and work within limits of competence and seek advice when needed
• Understanding of, and commitment to, equality, diversity and inclusion

Desirable

• Knowledge of the personalised care approach
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Knowledge of how the NHS works, including Primary Care and PCNs
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
• Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social

Qualifications

Essential

• Experience of working in a patient facing/customer service role or equivalent.

Desirable

• Experience of working within the NHS Experience of supporting patients with decision making
• Experience of working within multi- professional team environments
• Experience of supporting people, their families and carers in a related role
• Experience of data collection and using tools to measure the impact of services
• Phlebotomy training

Employer details

Employer name

Burbage Surgery

Address

9 Sprays

Burbage

Marlborough

Wiltshire

SN8 3TA

Employer's website

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