Job summary
West Suffolk Rural PCN are looking to recruit a Care Coordinator to join the team. The post is for 20 hours per week and will be based at Wickhambrook Surgery in Suffolk.
Working as part of a friendly team you will collaborate with a team of clinicians to support individuals in living healthy, independent lives, with a focus on self-management and preventative care. You will be instrumental in facilitating patient care by coordinating care and support needs across health and care services. You will play a crucial role in empowering patients to manage their conditions and improve their health outcomes.
The ideal candidate will be compassionate, organised and enthusiastic about improving patient care. You will have strong communication skills, both written and verbal, and be able to work efficiently as part of a team, with great flexibility.
Main duties of the job
- Care coordination and navigation
- Identify and support individuals with multiple long-term conditions, frailty, or health inequalities
- Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care
- Work closely with the practice patient services management team to aid with annual patient recall systems
- Document data on the computer system using clinical coding to ensure accurate retrieval of information for monitoring and audit purposes
- To provide coordination and navigation of patients, and where appropriate, their carers, across health and social care services, working hand in hand with social prescribing link workers health and wellbeing coaches, and other primary care professionals.
About us
West Suffolk Rural Primary Care Network (PCN) consists of 3 GP surgeries. Wickhambrook, Glemsford and Guildhall Clare surgeries, covering around 15,800 patients. PCN's are a national initiative from the NHS . The PCN offers a new way of organising care, bringing together all local health and care services in our local area to deliver more joined up care to local populations.
As part of the Suffolk Rural PCN, Wickhambrook surgery sits centrally in the countryside between Haverhill, Newmarket, Bury St Edmunds, Sudbury and Clare. We are served by a good road structure; however, bus links are infrequent so own transport is essential.
The advertised role is based at Wickhambrook surgery; a very friendly training practice, serving a patient population of 5,200. The clinical system we use is SystmOne, and we are proud of our consistently high achievement in the Quality and Outcomes Framework (QOF)
Supporting your work life balance and professional development is important to us, and we are happy to discuss any requirements with you. We offer the following benefits
- Supportive and friendly environment
- 20 days holiday (pro rata) + bank holidays
- NHS Pension
- Peer support
- Free car parking
Job description
Job responsibilities
- Assist with personal care plans for individual patients, ensuring preventative actions are detailed to support the appropriate use of services.
- To collate patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan in line with best practice
- Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care
- To provide coordination and navigation of patients, and where appropriate their carers across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW), health and wellbeing coaches, and other primary care professionals
- To support in the delivery of enhanced services and other service requirements on behalf of the PCN
- Support delivery of QOF, incentive schemes, QIPP and other quality or cost effectiveness initiatives
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level
- To run regular patient searches using the clinical IT system in order to have an up to date record of progress of achievement of Key Performance Indicators
- Work closely with the practice / PCN information and data manager to aid with annual patient recall systems
- Document data on the computer system using clinical coding to ensure accurate retrieval of information for monitoring and audit purpose
- Apply infection control measures in accordance with local and national guidelines
- Maintain recall system for national and annual health screening programs.
- Assist the clinical team in following up patients who have home treatment care, ensuring that any issues are recorded and followed up with the clinical team
- Maintain the at risk drug database ensuring that patients are sent blood monitoring paper work in a timely manner, escalating any concerns to patient GPs
- Process home blood pressure waiting list, to ensure that patients are contacted in priority order and equipment has is maintained and cleaned
- Participate in any practice development training sessions.
Job description
Job responsibilities
- Assist with personal care plans for individual patients, ensuring preventative actions are detailed to support the appropriate use of services.
- To collate patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan in line with best practice
- Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care
- To provide coordination and navigation of patients, and where appropriate their carers across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW), health and wellbeing coaches, and other primary care professionals
- To support in the delivery of enhanced services and other service requirements on behalf of the PCN
- Support delivery of QOF, incentive schemes, QIPP and other quality or cost effectiveness initiatives
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level
- To run regular patient searches using the clinical IT system in order to have an up to date record of progress of achievement of Key Performance Indicators
- Work closely with the practice / PCN information and data manager to aid with annual patient recall systems
- Document data on the computer system using clinical coding to ensure accurate retrieval of information for monitoring and audit purpose
- Apply infection control measures in accordance with local and national guidelines
- Maintain recall system for national and annual health screening programs.
- Assist the clinical team in following up patients who have home treatment care, ensuring that any issues are recorded and followed up with the clinical team
- Maintain the at risk drug database ensuring that patients are sent blood monitoring paper work in a timely manner, escalating any concerns to patient GPs
- Process home blood pressure waiting list, to ensure that patients are contacted in priority order and equipment has is maintained and cleaned
- Participate in any practice development training sessions.
Person Specification
Experience
Essential
- * Proactive, with excellent communication and organisational skills, ideally with experience in healthcare, social care, or education
- * Ability to manage a caseload
- * Experience in supporting individuals or working in a multidisciplinary team
- * Proficiency in Microsoft Office applications (Word, Excel, Outlook)
- * Access to own transport
Desirable
- * Experience of working in primary care
- * Experience in a care coordinator role or with elderly or vulnerable people
- * Experience in data collection and using tools to measure service impact
- * Previous working knowledge of SystmOne clinical system
Person Specification
Experience
Essential
- * Proactive, with excellent communication and organisational skills, ideally with experience in healthcare, social care, or education
- * Ability to manage a caseload
- * Experience in supporting individuals or working in a multidisciplinary team
- * Proficiency in Microsoft Office applications (Word, Excel, Outlook)
- * Access to own transport
Desirable
- * Experience of working in primary care
- * Experience in a care coordinator role or with elderly or vulnerable people
- * Experience in data collection and using tools to measure service impact
- * Previous working knowledge of SystmOne clinical system
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.