Job summary
ARRS CARE COORDINATOR - Full-Time (37.5 hours / week)
Are you
passionate about improving patient care and making a real difference in
peoples lives? We are looking for a Care Coordinator to join our
friendly and supportive GP practice, helping patients navigate their healthcare
journey with ease.
As a key part
of our multidisciplinary team, you will work closely with GPs, pharmacists,
nurses, and social prescribers, Age UK, Safeguarding and Palliative Care Teams, to ensure patients receive the right care at the
right time.
You will coordinate referrals, assist with care planning, and
support patients with long-term conditions, complex health & care needs, be required to see patients face to face, reducing hospital admissions and
enhancing their wellbeing.
This is an exciting
opportunity to work in a fast pace patient centred environment where
your organisational skills, compassion, and problem-solving abilities will
truly make an impact. If you thrive in a collaborative setting and want to be
part of a team that values and promotes professional growth and patient-centred care, wed
love to hear from you.
Main duties of the job
The Care Coordinator will support patients with mental health needs, dementia, learning disabilities, cancer, and general wellbeing concerns by managing caseloads and coordinating their care across Primary, Secondary, and Community services.
The role involves referring patients to appropriate health professionals, supporting external referrals, and ensuring patients benefit from available services.
Additionally, the post holder will provide administrative support, assist with QOF and DES/LES work, coordinate care plans, engage with vulnerable patient groups and their carers, and organise key meetings to facilitate effective patient care.
Fulfil other administrative duties as required to support the smooth running of the practice.
About us
ABOUT ALBANY HOUSE MEDICAL CENTRE, OUR VALUES AND BEHAVIOURS
Our purpose is to deliver the best possible care for all the people who visit our practices, either as patients, the public or as staff.
As one of the largest and busiest surgeries in Wellingborough, our vision is to move from where we are now to where we want to be, the journey from good to great.
In undertaking this role you are expected at all times to behave in accordance with our practice values which demonstrate your commitment to the delivery of high quality services to patients. This will be in accordance with agreed objectives, quality standards, and resource constraints.
Our values are:
- We treat patients, service users, and each other with kindness, dignity and respect
- Services are always designed around the Patient
- We deliver services that are well managed, efficient, convenient and accessible for patients
- We do what we say we are going to do
- We are one team and work best when we work together
Job description
Job responsibilities
Key Working Relationships
- Patients / members of the public
- GPs, Registrars and medical students
- Practice Staff
- Local Health Authorities
- District Nurses
- Health Visitors and Midwives
- Community and Practice Clinical Pharmacists
- Social Prescribers
- Age Well/Age UK and other Primary Care Network
assets
- CCG Safeguarding nurse for primary
care
- 0-19 nursing team (health visitor
& school nurses)
- Community midwife
- MASH health
- MARAC health
- MAPPA coordinator
- Early Help
- Acute
and community trust safeguarding leads
KEY DUTIES:
Safeguarding
Help the practice
to ensure safeguarding policies and procedures are up to date and consistent
with agreed best practice as defined by local and national guidelines.
Support the
practice in developing/accessing appropriate role-based training for members
of staff. Help the practice run training events which encourage a
multidisciplinary approach to safeguarding.
Provide advice
and training on the recording and coding of safeguarding relevant information
within the electronic patient record. Support the preparation of timely,
relevant, and proportionate safeguarding reports.
Facilitate the
implementation of templates and other decision support tools to support best
practice in safeguarding, as recommended by the Northamptonshire safeguarding
team and audit the use of same.
Support the
practice in achieving CQC compliance with respect to the safeguarding of
staff and patients.
Take a key role
in the development and running of an effective practice safeguarding MDT for
children and vulnerable adults. Ensure that the practice has a vulnerable
patient register which is kept up to date.
Help the practice
foster effective relationships with local safeguarding partners. Ensure the
timely sharing of relevant information, both verbally and in a structured
report, when safeguarding concerns arise in respect of both children and
adults.
Support the
practice in responding to statutory requests for information required by the local
authority to carry out local child or adult safeguarding case reviews and
assist the practice with section 42 enquiries. Disseminate learning and
support the implementation of review recommendations.
Undertake regular
audits as requested by line manager and present at educational meetings to
ensure compliance and enhance education
Promote the
understanding of local safeguarding referral pathways, including Early Help
and support services for victims of domestic abuse.
Attend meetings and training sessions (internal and external) in regards to safeguarding matters, representing the practice and sharing knowledge and information as required.
QOF/LES/DES Reviews
- Identify patients who fall within national and
practice criteria
- Call/Recall patients in a timely manner
- Perform initial telephone/video/face to face
assessments
- Liaise with usual GP with any area of concern
- Update SystmOne care plans as appropriate
- Coordinate referrals to social prescribers
- Work with Wellingborough PCN teams for
patient care plans and reviews
- Where appropriate work with clinicians to
discuss escalation care plans and where required end of life preferences with patients
and their carers
- Coordinate any safeguarding concerns with the
practice safeguarding leads and attend internal safeguarding meetings
Action Discharge summaries
- Review hospital discharge summaries for
adults, families, carers (excluding care homes)
- Code admission and reason
- Contact the patient within 48 hours of
discharge to offer support and discuss care needs. Signpost to services as
appropriate i.e. Practice social prescriber, clinical pharmacist and local
frailty teams.
- Diarise to follow up with patient as
appropriate
- Liaise with usual GP with any area of concern.
- Where appropriate liaise with hospital staff
whilst patient is an inpatient and support to enable discharge
- Set up a spreadsheet to record contacts and
outcomes
- Audit hospital admissions in 3 months to
identify any common themes, frequent flyers
- Attend meetings as and when required including
MDT, Practice meetings
- Provide a quarterly update to CCG as per
contract July, October, January and April
This
list is not exhaustive and any tasks/roles that will
assist the practice may be required.
Job description
Job responsibilities
Key Working Relationships
- Patients / members of the public
- GPs, Registrars and medical students
- Practice Staff
- Local Health Authorities
- District Nurses
- Health Visitors and Midwives
- Community and Practice Clinical Pharmacists
- Social Prescribers
- Age Well/Age UK and other Primary Care Network
assets
- CCG Safeguarding nurse for primary
care
- 0-19 nursing team (health visitor
& school nurses)
- Community midwife
- MASH health
- MARAC health
- MAPPA coordinator
- Early Help
- Acute
and community trust safeguarding leads
KEY DUTIES:
Safeguarding
Help the practice
to ensure safeguarding policies and procedures are up to date and consistent
with agreed best practice as defined by local and national guidelines.
Support the
practice in developing/accessing appropriate role-based training for members
of staff. Help the practice run training events which encourage a
multidisciplinary approach to safeguarding.
Provide advice
and training on the recording and coding of safeguarding relevant information
within the electronic patient record. Support the preparation of timely,
relevant, and proportionate safeguarding reports.
Facilitate the
implementation of templates and other decision support tools to support best
practice in safeguarding, as recommended by the Northamptonshire safeguarding
team and audit the use of same.
Support the
practice in achieving CQC compliance with respect to the safeguarding of
staff and patients.
Take a key role
in the development and running of an effective practice safeguarding MDT for
children and vulnerable adults. Ensure that the practice has a vulnerable
patient register which is kept up to date.
Help the practice
foster effective relationships with local safeguarding partners. Ensure the
timely sharing of relevant information, both verbally and in a structured
report, when safeguarding concerns arise in respect of both children and
adults.
Support the
practice in responding to statutory requests for information required by the local
authority to carry out local child or adult safeguarding case reviews and
assist the practice with section 42 enquiries. Disseminate learning and
support the implementation of review recommendations.
Undertake regular
audits as requested by line manager and present at educational meetings to
ensure compliance and enhance education
Promote the
understanding of local safeguarding referral pathways, including Early Help
and support services for victims of domestic abuse.
Attend meetings and training sessions (internal and external) in regards to safeguarding matters, representing the practice and sharing knowledge and information as required.
QOF/LES/DES Reviews
- Identify patients who fall within national and
practice criteria
- Call/Recall patients in a timely manner
- Perform initial telephone/video/face to face
assessments
- Liaise with usual GP with any area of concern
- Update SystmOne care plans as appropriate
- Coordinate referrals to social prescribers
- Work with Wellingborough PCN teams for
patient care plans and reviews
- Where appropriate work with clinicians to
discuss escalation care plans and where required end of life preferences with patients
and their carers
- Coordinate any safeguarding concerns with the
practice safeguarding leads and attend internal safeguarding meetings
Action Discharge summaries
- Review hospital discharge summaries for
adults, families, carers (excluding care homes)
- Code admission and reason
- Contact the patient within 48 hours of
discharge to offer support and discuss care needs. Signpost to services as
appropriate i.e. Practice social prescriber, clinical pharmacist and local
frailty teams.
- Diarise to follow up with patient as
appropriate
- Liaise with usual GP with any area of concern.
- Where appropriate liaise with hospital staff
whilst patient is an inpatient and support to enable discharge
- Set up a spreadsheet to record contacts and
outcomes
- Audit hospital admissions in 3 months to
identify any common themes, frequent flyers
- Attend meetings as and when required including
MDT, Practice meetings
- Provide a quarterly update to CCG as per
contract July, October, January and April
This
list is not exhaustive and any tasks/roles that will
assist the practice may be required.
Person Specification
Experience
Essential
- - Experience of working within a healthcare team
- - Experience of dealing with vulnerable patient
Desirable
- - Experience of working in primary care
- - Experience of working in a GP practice
- - Experience of utilising SystmOne
- - knowledge of QOF and DES/LES requirements
Qualifications
Essential
- - GCSE grade A to C in English and Maths
Desirable
- - Qualified to NVQ level 2 in Health and Social Care
Person Specification
Experience
Essential
- - Experience of working within a healthcare team
- - Experience of dealing with vulnerable patient
Desirable
- - Experience of working in primary care
- - Experience of working in a GP practice
- - Experience of utilising SystmOne
- - knowledge of QOF and DES/LES requirements
Qualifications
Essential
- - GCSE grade A to C in English and Maths
Desirable
- - Qualified to NVQ level 2 in Health and Social Care
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.
