Job summary
Cambridge Northern Villages PCN (Primary Care
Network) is looking to recruit a Care Coordinator to join our PCN team. Each
Care Coordinator has a primary practice base, although will be required to
provide support to the other practices within the PCN, striving to provide high
quality patient care.
The main roles of the successful applicant will be
to proactively communicate information between patients, doctors and
professionals and to assist the clinical teams with administrative functions
within the practice. There will be peer-learning opportunities for the care
coordinators across the PCN and also training and development opportunities.
This role requires excellent communication and
organisational skills including an ability to prioritise, multitask and work to
deadlines. The role will be a key member of the base practice team and the
successful applicant would need to work to a high standard with all members of
the team
This role will be covering and supporting all practices within the PCN - although a hub based model is being considered, there may be requirements to travel within the PCN from time to time.
If you are a forward thinking
individual who is keen to develop in this role, we want to hear from you!
Main duties of the job
To use clinical systems to identify,
prioritise and contact patients requiring health checks or recalls.
- To
coordinate multi-disciplinary working within the practice and to
facilitate onward referrals to external services.
- Liaising with local hospitals to follow up
patient referrals
- To
support the practice in quality improvement programmes with a focus on
improved patient care
- To
contact patients with learning disability or severe mental illness prior
to their annual health check and support them to attend
- To
contact patients following a recent change in medical circumstances for
the purposes of welfare checks and/or follow up appointments. This will
include all recent hospital discharges
- To
arrange regular appointments with patients who require them (e.g. INR
checks)
- To
facilitate shared decision making with patients, their carers and
clinicians.
- To
support patients with care navigation and make onward referrals as
appropriate.
- To
support practice staff with care navigation.
- To
develop a sound understanding of the local provider landscape and
disseminate relevant information to colleagues as required.
- Effectively
communicate a patients needs within a multidisciplinary team meeting
environment
- Implement
and follow up key action points from the MDT meetings on to the agreed
care plan which is clear and concise contemporaneous
About us
We endeavour to recognise the value of our team members individually & collectively & to encourage their personal & professional development. We are committed to providing an open, and supportive environment where all staff are comfortable sharing ideas & can expect to be provided with all the tools and support they need to enjoy working and succeeding.
We are looking to expand our PCN services to support our patients pathway and support them within the journey of Primary care. Our Team currently consists of 2 Clinical Directors, 1 PCN Manager, 3 Clinical Pharmacists, 1 First Contact Physiotherapist and 1 Social Prescriber.
Cambridge Northern Villages PCN is made
up of the following practices:
Cottenham Surgery, Cottenham,
Firs House Medical Partnership- Histon
Maple Surgery, Bar Hill.
Milton Surgery, Milton.
Over Surgery, Over.
Swavesey Surgery, Swavesey.
Waterbeach Surgery, Waterbeach.
Willingham Medical Practice, Willingham.
Job description
Job responsibilities
As a Care Coordinator you will be
working closely alongside your PCN
(Primary Care Network) team to support people through personalised care,
helping people to improve their health and wellbeing.
Care coordinators will
play an important role within a PCN to proactively identify and work with
people, including the frail/elderly and those with long-term conditions, to
provide coordination and navigation of care and support across health and care
services.
The care coordinator role
will ensure patient health and care planning is timely, efficient, and
patient-centred. The role will include responsibilities for the coordination of
the patients journey through primary care and secondary care.
- Completing and submitting quality alerts as
appropriate.
- Dealing with requests for information (e.g
MASH).
- Contacting/chasing patients as requested by
the Clinicians.
- Pro-actively ensuring that booked appointments
are appropriate & with the correct clinician
- Overseeing reports and prompting Doctors when
urgent. Preparation of
- eGPRs where necessary.
- Look up results on the EPR system or chase
with hospital/lab
- Assisting clinicians with Care Plans.
Coordinating & actioning admin aspects of care plans.
- Undertaking quality improvement and change in
practice. Assist with audits as required
- Understanding the importance of medical
terminology, data and coding
- Record keeping with use of appropriate coding.
- Understand vulnerable groups and long term
illness. Use of patient information resources
- To work as a positive and active member within
the PCN Teams
- Participate in any training programmes as
agreed with the PCN Manager
- Work safely at all times in accordance with
Legislative requirements and Practice Policies and Procedures.
Identify
and process any safeguarding and quality of care issues and refer onwards to
ensure that clients welfare is protected as per agreed protocols.
Support
the coordination and delivery of MDTs within the PCN
Work
with the GPs and other primary care professionals within the PCN to identify
and manage a caseload of patients, and where required and as appropriate, refer
people back to other health professionals within the PCN
- Be a good communicator; have
excellent written and verbal communication skills.
- Supporting in the planning and
monitoring of projects.
- Planning and organising meetings
when requested.
- Co-ordinating and organising
project information, data and documents.
- Work autonomously on own areas of
work seeking support from colleagues where expertise is required and
escalating issues and concerns as necessary.
- Promote all vision and values of
the PCN in all day to day activities and delivery of services.
- To undertake statutory and
mandatory training and other training as and when required.
- To assist the doctors and other clinicians in
the provision of a high quality service.
- Answering general enquiries, making new and
follow up appointments.
- Seeking patient information and results from
hospitals and other organisations.
- Liaise with hospitals for updates on patients
or advise of any relevant changes in patients condition as directed by
clinicians.
This job
description is not exhaustive and may be adjusted periodically after review and
consultation. You will also be expected to carry out any reasonable duties that
may be requested from time-to-time.
The
post holder is expected to develop and maintain effective working relationships
with a range of stakeholders, both internal and external to the practice. The stakeholders include, but are not limited
to:
- Head of Transformation
- Partnership and Transformation
Programme Manager
- Practice staff
- Community FICS
- Living Well Team (social
prescribing)
- First Contact Physiotherapists
(FCPs)
- Primary Care Mental Health
Practitioners
- Community, Health & Social Care
Colleagues
- 111
- Local Hospitals
- Residential
Care within the PCN
Job description
Job responsibilities
As a Care Coordinator you will be
working closely alongside your PCN
(Primary Care Network) team to support people through personalised care,
helping people to improve their health and wellbeing.
Care coordinators will
play an important role within a PCN to proactively identify and work with
people, including the frail/elderly and those with long-term conditions, to
provide coordination and navigation of care and support across health and care
services.
The care coordinator role
will ensure patient health and care planning is timely, efficient, and
patient-centred. The role will include responsibilities for the coordination of
the patients journey through primary care and secondary care.
- Completing and submitting quality alerts as
appropriate.
- Dealing with requests for information (e.g
MASH).
- Contacting/chasing patients as requested by
the Clinicians.
- Pro-actively ensuring that booked appointments
are appropriate & with the correct clinician
- Overseeing reports and prompting Doctors when
urgent. Preparation of
- eGPRs where necessary.
- Look up results on the EPR system or chase
with hospital/lab
- Assisting clinicians with Care Plans.
Coordinating & actioning admin aspects of care plans.
- Undertaking quality improvement and change in
practice. Assist with audits as required
- Understanding the importance of medical
terminology, data and coding
- Record keeping with use of appropriate coding.
- Understand vulnerable groups and long term
illness. Use of patient information resources
- To work as a positive and active member within
the PCN Teams
- Participate in any training programmes as
agreed with the PCN Manager
- Work safely at all times in accordance with
Legislative requirements and Practice Policies and Procedures.
Identify
and process any safeguarding and quality of care issues and refer onwards to
ensure that clients welfare is protected as per agreed protocols.
Support
the coordination and delivery of MDTs within the PCN
Work
with the GPs and other primary care professionals within the PCN to identify
and manage a caseload of patients, and where required and as appropriate, refer
people back to other health professionals within the PCN
- Be a good communicator; have
excellent written and verbal communication skills.
- Supporting in the planning and
monitoring of projects.
- Planning and organising meetings
when requested.
- Co-ordinating and organising
project information, data and documents.
- Work autonomously on own areas of
work seeking support from colleagues where expertise is required and
escalating issues and concerns as necessary.
- Promote all vision and values of
the PCN in all day to day activities and delivery of services.
- To undertake statutory and
mandatory training and other training as and when required.
- To assist the doctors and other clinicians in
the provision of a high quality service.
- Answering general enquiries, making new and
follow up appointments.
- Seeking patient information and results from
hospitals and other organisations.
- Liaise with hospitals for updates on patients
or advise of any relevant changes in patients condition as directed by
clinicians.
This job
description is not exhaustive and may be adjusted periodically after review and
consultation. You will also be expected to carry out any reasonable duties that
may be requested from time-to-time.
The
post holder is expected to develop and maintain effective working relationships
with a range of stakeholders, both internal and external to the practice. The stakeholders include, but are not limited
to:
- Head of Transformation
- Partnership and Transformation
Programme Manager
- Practice staff
- Community FICS
- Living Well Team (social
prescribing)
- First Contact Physiotherapists
(FCPs)
- Primary Care Mental Health
Practitioners
- Community, Health & Social Care
Colleagues
- 111
- Local Hospitals
- Residential
Care within the PCN
Person Specification
Experience
Essential
- Experience of working in a fast-paced environment, requiring a flexibility with an emphasis on using your own initiative
- Adapting to change within the workplace
- Working co-operatively with colleagues
- Experience of working with highly confidential or sensitive or information.
- I.T. literate and the ability to confidently use email, excel and data software.
- Strong organisational skills
- Understanding confidentiality and data protection
- Proven ability to prioritize workloads and meet deadline
- Proven experience of working as part of a team.
- Proven ability to work with people in a supportive capacity
- Experience of creating person-centred care/action plans.
- Passionate about achieving excellence in patient care
- Skills/Knowledge Awareness and understanding of the relevant Health and Social Care legislation.
- Comprehensive working knowledge of Microsoft Office, especially word and excel
- Excellent planning, organisation and communication skills
- An ability to work on own initiative and manage own workload.
- Be able to communicate clearly and appropriately with members of the public, colleagues and staff in other agencies verbally, on the telephone and in writing.
- Flexible, adaptable and resourceful.
Desirable
- Experience of SystmOne/EMIS/other clinical system
- Previous relevant experience using electronic Referral Service - eRS
- Previous experience of working in primary care, the NHS or Social Care.
- Experience of working with people with learning disabilities and/or serious mental illness
Qualifications
Essential
- Higher level of education (e.g. NVQ level 3 or A levels at minimum or equivalent)
- Good standard of education (min GCSE English & Maths, or equivalent)
Person Specification
Experience
Essential
- Experience of working in a fast-paced environment, requiring a flexibility with an emphasis on using your own initiative
- Adapting to change within the workplace
- Working co-operatively with colleagues
- Experience of working with highly confidential or sensitive or information.
- I.T. literate and the ability to confidently use email, excel and data software.
- Strong organisational skills
- Understanding confidentiality and data protection
- Proven ability to prioritize workloads and meet deadline
- Proven experience of working as part of a team.
- Proven ability to work with people in a supportive capacity
- Experience of creating person-centred care/action plans.
- Passionate about achieving excellence in patient care
- Skills/Knowledge Awareness and understanding of the relevant Health and Social Care legislation.
- Comprehensive working knowledge of Microsoft Office, especially word and excel
- Excellent planning, organisation and communication skills
- An ability to work on own initiative and manage own workload.
- Be able to communicate clearly and appropriately with members of the public, colleagues and staff in other agencies verbally, on the telephone and in writing.
- Flexible, adaptable and resourceful.
Desirable
- Experience of SystmOne/EMIS/other clinical system
- Previous relevant experience using electronic Referral Service - eRS
- Previous experience of working in primary care, the NHS or Social Care.
- Experience of working with people with learning disabilities and/or serious mental illness
Qualifications
Essential
- Higher level of education (e.g. NVQ level 3 or A levels at minimum or equivalent)
- Good standard of education (min GCSE English & Maths, or equivalent)
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.
