Job summary
We are looking to recruit 2 new motivated and enthusiastic Care Coordinators to join our dynamic primary care network (PCN) and work as part of a
multi-disciplinary team within the East Kennet area of rural Wiltshire.
Our PCN is a collaborative group of GPs whose surgeries are
focal points within their communities.
If you want to be part of a great PCN team with immense job satisfaction, while making a difference to patient care
in a more meaningful way then this may be the opportunity for you!
Main duties of the job
The role will suit self-motivated individual who is proactive and can collaborate with different services. Training and support will be provided as required.
Main duties of the job:
Work with patients, their families and carers to improve their understanding of the patients’ condition and support them to develop and review Personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Ensuring that people have good quality written or verbal information to help them make choices about their care.
Assist patients to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing
Support people to take up training and employment, and to access appropriate benefits where eligible; for example, through referral to social prescribing link workers.
Provide coordination and navigation for patient and their carers across health and care services, working closely with health and wellbeing services.
Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions and cancer care.
About us
Primary Care Network (PCN) are a new development in the NHS.
East Kennet PCN is made up of four local GP Practices with a combined patient list
size of 37,000. The Practices are Kennet & Avon Medical Partnership,
Ramsbury & Wanborough Surgery, Old School Surgery Great Bedwyn and Burbage
Surgery.
As a Care Coordinator you
will play a key role in Primary Care Network in supporting the
practices.
We are a welcoming, friendly and supportive team with a
great environment where you will be highly valued.
Job description
Job responsibilities
Overall responsibility for arranging the PCN led MDT meetings (including the weekly virtual Care Home(s) MDT and the cancer and palliative care meetings) and the smooth running of integrated care within the team setting.
Manage reporting required and associated within the NHSE DES specifications for required services.
Patient Identification Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
Receive and 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
Direct patient facing work
Manage a caseload of patients
Support PCN with Cancer cohorts and guidance, arrange cancer information workshop for practices, provide support to patients to facilitate access to screening and assist with early diagnosis of cancer, ensure patients have their cancer reviews.
Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT
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.
Job description
Job responsibilities
Overall responsibility for arranging the PCN led MDT meetings (including the weekly virtual Care Home(s) MDT and the cancer and palliative care meetings) and the smooth running of integrated care within the team setting.
Manage reporting required and associated within the NHSE DES specifications for required services.
Patient Identification Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
Receive and 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
Direct patient facing work
Manage a caseload of patients
Support PCN with Cancer cohorts and guidance, arrange cancer information workshop for practices, provide support to patients to facilitate access to screening and assist with early diagnosis of cancer, ensure patients have their cancer reviews.
Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT
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.
Person Specification
Experience
Essential
- An appreciation of the NHS agenda and government targets, especially in relation to general practice.
- Awareness of systems to support management of patients in a primary care setting.
- Awareness of medical knowledge and terminology.
Desirable
- A working knowledge of primary care and GP clinical systems, such as SystmOne
Qualifications
Essential
- GCSEs/Diploma/ HNC level (or relevant experience) ECDL or equivalent NVQ Level 3 Business Administration (or relevant experience) Ongoing internal and external training to keep up to date with changes/ developments
Person Specification
Experience
Essential
- An appreciation of the NHS agenda and government targets, especially in relation to general practice.
- Awareness of systems to support management of patients in a primary care setting.
- Awareness of medical knowledge and terminology.
Desirable
- A working knowledge of primary care and GP clinical systems, such as SystmOne
Qualifications
Essential
- GCSEs/Diploma/ HNC level (or relevant experience) ECDL or equivalent NVQ Level 3 Business Administration (or relevant experience) Ongoing internal and external training to keep up to date with changes/ developments
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).