Care Coordinator - Admin role in GP services

Job description

Job responsibilities

The Care Coordinator will undertake work in line with PCN directed priorities, work within their scope of practice. The successful applicant will:

1. Support the PCN & MDT

a. Overall responsibility for arranging the weekly PCN led MDT meetings within agreed projects/workstreams to ensure and the smooth running of integrated care within the team setting.

b. The key role of the Care Coordinator will be to coordinate and manage the administrative functions of PCN & MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.

c. Liaise with all clinical and non-clinical members in the PCN & MDT to ensure effective function.

d. Take minutes of PCN & MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.

e. Manage reporting required and associated within the Directed Enhanced Service (DES) contract specifications for required services.

2. Support patients:

a. Work with people, 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.

b. 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.

c. Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure (PAM).

d. 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.

e. Support people to take up training and employment, and to access appropriate benefits where eligible.

f. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.

g. 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 where appropriate, refer back to other health professionals within the PCN.

h. Support the coordination and delivery of multidisciplinary teams with the PCN.

i. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.

j. Explore and assist people to access a personal health budget where appropriate.

k. Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided.

l. Utilise population health intelligence to proactively identify a cohort of patients to deliver personalised care.

3. Support data collection:

a. Ensure timely and accurate information analysis, ensuring the IT requirements for recording activity are adhered to in collaboration with other team members.

b. Maintain accurate and up to date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e., entering notes onto EMIS using agreed read codes.

c. To provide agreed performance/activity data within the PCN & MDT.

d. Appropriate management of collected data, ensuring all data is kept and shared in accordance with all relevant governance requirements.

e. Validate and quality assure incoming data, and to provide guidance on the data where a range of outcomes or options are available.

f. Run regular patient searches using EMIS in order to have an up-to-date record of progress of achievement of Key Performance Indicators.

g. Support the PCN in providing key performance indicator (KPI) reports for submission as requested.

h. Support delivery of the Quality Outcomes Framework (QOF), incentive schemes, Quality Innovation, Productivity and Prevention (QIPP) and other quality or cost effectiveness initiatives as required.

4. Support the PCN Board and associated practices.

a. Maintain productive working relations with senior clinical, operational and corporate colleagues.

b. Provide admin support to the PCN projects as required, attending PCN, MDT meetings plus any other meetings where there is a need to discuss PCN/practice data.

c. Support the PCN board and individual practices with any training, workshops and planning sessions.

d. Liaise with primary, secondary and specialist care services as required.

e. Support in the delivery of enhanced services and other service requirements on behalf of the PCN.

f. Undertake any other duties, as specified by the PCN Manager to meet the evolving needs of the organisation.

g. Plan and prioritise multiple tasks and activities, to ensure all regular, ad hoc and mandatory reporting requirements are met along-side project-based work-streams.

h. Present information related to data or reporting issues, explaining complex issues, to a wide range of internal and external stakeholders.

i. Present data in such a way that the information is accessible for use by a wide range of internal and external sources without expert knowledge.

There may be, on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels.

Person Specification

Experience

Essential

• Demonstrable commitment to professional and personal development
• Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook
• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience of working within multi- professional team environments
• Experience of supporting people, their families and carers in a related role
• Experience of data collection and using tools to measure the impact of services

Desirable

• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health /health improvement
• Experience or training in personalised care and support planning
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
• Experience of project management in a healthcare or voluntary setting.
• Experience of working in a GP Practice or within primary care
• Experience of using clinical systems e.g. System One, EMIS, Ardens

Skills & Knowledge

Essential

• Knowledge of the personalised care approach
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Knowledge of how the NHS works, including primary care and PCNs
• Ability to recognise and work within limits of competence and seek advice when needed
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social

Desirable

• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes

Personal qualities and Attributes

Essential

• Ability to actively listen, empathise with people and provide personalised support in a non-judgmental way
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
• Ability to identify risk and assess / manage risk when working with individuals
• Ability to demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• High level of written and verbal communication skills
• Ability to work flexibly and enthusiastically within a team or on own initiative

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.

Employer details

Employer name

The Leyland Primary Care Network

Address

Worden Medical Centre

West Paddock

Leyland

Lancashire

PR25 1HR

Employer's website

https://www.wordenmc.net/ (Opens in a new tab)