Job summary
Care Co-ordinator required to work at Thatcham Medical
Practice. This exciting new role requires previous experience within social
care or relevant field or NHS experience.
The successful candidate will be willing to enrol in, or be qualified with
appropriate training as set out by the Personalised Care Institute.
Main duties of the job
Help reduce health inequalities by working with patients
and carers to deliver personalised care plans, using decision aids in preparation
for better conversations.
Work closely
with social prescribers and the multidisciplinary team to help navigate patients
to appropriate care and local services.
Communicate
effectively with a wide range of service providers and assist with MDT meetings.
Help improve accessibility in general practice by helping
to organise and plan group consultations including virtual and face-to face group
consultations.
About us
Thatcham Medical Practice has just under 18,800 patients. We
are a dynamic training practice and work closely together with our PCN. We pride
ourselves on our ability to adapt new ways of working to ensure we continually
meet the diverse needs of our patient population. We offer professional development within a
supportive learning environment. We have a fantastic multidisciplinary team who
work hard but also enjoy a catch up over coffee!
Job description
Job responsibilities
Primary Duties and Areas of Responsibility
Multi-Disciplinary Teams
- Responsibility for assisting with arranging the monthly MDT meetings (including the weekly virtual Care Home(s) MDT) and the smooth running of integrated care within the team setting. A key role of the Care Coordinator will be to help schedule weekly virtual care home MDT meetings as required.
- Help to provide background information about individuals for the MDT meetings Take minutes of the MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
- Support reporting required and associated within the NHSE DES specifications for required services.
- Support the use of population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
- Help to collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.
- Liaise with service providers and clinicians to identify ‘frequent flyers’, and new service users utilising risk stratification tools provided and present this information to the weekly MDT meetings.
- Signpost team members, service users and carers to relevant services
- Work with practice staff on new innovative ideas to improve accessibility in general practice, this includes coordinating virtual and face-to-face group consultations focusing on chronic disease in our community.
- Organise and plan group consultations for chronic conditions including doing patient searches, using EMIS and accuRx to identify and invite patients. Coordinate with relevant parties to run these groups.
Direct patient facing work
- Support patients to utilise decision aids in preparation for a shared decision-making conversation.
- Holistically bring together all of a person’s identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
- 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.
- 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.
- Communicate effectively with service users and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and other primary care professionals.
- Liaise with other stakeholders as needed for the collective benefit of patients including but not limited to Patient’s GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations. Also, wider service networks including the voluntary sector and adult social care
- Work with Care Homes to ensure new referrals are logged and allocated. Acting as a point of contact for residents, families, carers and professionals who visit the care home, such as MDT members and in-reach specialists
- Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT
Other responsibilities
- To act at all times in an anti-discriminatory manner
- To be able to plan and respond to workload according to operational priorities
- To support the delivery of these functions across wider locality areas where necessary
- To undertake any training required in order to maintain competency including mandatory training
- To contribute to, and work within a safe working environment.
- The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practice’s equal opportunity policies and procedures
- The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.
Patient Care
- Communicate effectively and sensitively and use language appropriate to a patient and carer/relative’s condition and level of understanding
- Effectively use all methods of communication and be aware of and manage barriers to communication
- The Care Coordinator will be given opportunity to discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with a relevant GP.
Supporting Care Delivery
- Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated
- Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.
- Follow through with service users and others involved to ensure all services and care arrangements are in place.
- (see attached job description for full details)
Job description
Job responsibilities
Primary Duties and Areas of Responsibility
Multi-Disciplinary Teams
- Responsibility for assisting with arranging the monthly MDT meetings (including the weekly virtual Care Home(s) MDT) and the smooth running of integrated care within the team setting. A key role of the Care Coordinator will be to help schedule weekly virtual care home MDT meetings as required.
- Help to provide background information about individuals for the MDT meetings Take minutes of the MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
- Support reporting required and associated within the NHSE DES specifications for required services.
- Support the use of population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
- Help to collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.
- Liaise with service providers and clinicians to identify ‘frequent flyers’, and new service users utilising risk stratification tools provided and present this information to the weekly MDT meetings.
- Signpost team members, service users and carers to relevant services
- Work with practice staff on new innovative ideas to improve accessibility in general practice, this includes coordinating virtual and face-to-face group consultations focusing on chronic disease in our community.
- Organise and plan group consultations for chronic conditions including doing patient searches, using EMIS and accuRx to identify and invite patients. Coordinate with relevant parties to run these groups.
Direct patient facing work
- Support patients to utilise decision aids in preparation for a shared decision-making conversation.
- Holistically bring together all of a person’s identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
- 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.
- 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.
- Communicate effectively with service users and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and other primary care professionals.
- Liaise with other stakeholders as needed for the collective benefit of patients including but not limited to Patient’s GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations. Also, wider service networks including the voluntary sector and adult social care
- Work with Care Homes to ensure new referrals are logged and allocated. Acting as a point of contact for residents, families, carers and professionals who visit the care home, such as MDT members and in-reach specialists
- Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT
Other responsibilities
- To act at all times in an anti-discriminatory manner
- To be able to plan and respond to workload according to operational priorities
- To support the delivery of these functions across wider locality areas where necessary
- To undertake any training required in order to maintain competency including mandatory training
- To contribute to, and work within a safe working environment.
- The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practice’s equal opportunity policies and procedures
- The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.
Patient Care
- Communicate effectively and sensitively and use language appropriate to a patient and carer/relative’s condition and level of understanding
- Effectively use all methods of communication and be aware of and manage barriers to communication
- The Care Coordinator will be given opportunity to discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with a relevant GP.
Supporting Care Delivery
- Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated
- Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.
- Follow through with service users and others involved to ensure all services and care arrangements are in place.
- (see attached job description for full details)
Person Specification
Qualifications
Essential
- GCSE A to C in English and Maths
- ECDL or equivalent
- NVQ level 2 /3 or equivalent
Desirable
- NVQ level 3 Business Administration (or relevant experience , including clinical experience
Experience
Essential
- Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
Desirable
- Experience of working in primary care or in a GP practice helpful.
Person Specification
Qualifications
Essential
- GCSE A to C in English and Maths
- ECDL or equivalent
- NVQ level 2 /3 or equivalent
Desirable
- NVQ level 3 Business Administration (or relevant experience , including clinical experience
Experience
Essential
- Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
Desirable
- Experience of working in primary care or in a GP practice helpful.
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.
