Job summary
An exciting opportunity has arisen for a Care Co-ordinator
to join Surrey Heath Primary Care Network [PCN], supporting delivery of the new
Network Contract Direct Enhanced Service [DES] specifications.
We are looking for four Care Co-ordinators to support our PCN,
to work closely with PCN Practices and the multidisciplinary team in
coordinating all key activities including access to services, advice, and
information, and ensuring heath and care planning is timely, efficient, and
patient-centred. The post holder will help patients interact and engage with
everyday life through activities designed to develop, maintain, or retrain
skills for people with a cognitive, physical, or mental disorder, condition, or
illness. You will support the provision of continuity of care and act as a
point of contact for families, residents, and professionals for identified
patients in your caseload.
Full time and Part time available, we operate as a 7 day service from 8am - 8pm.
The post holder will be based at one of the following practices - Bartlett Group Practice, Park House Surgery and Park Road Group Practice.
Main duties of the job
The successful candidate will have experience of
EMIS web or similar patient management software and Excel spreadsheet knowledge
for regular reporting. Other duties will also include;
To coordinate, monitor and deliver projects and
services clinical campaigns
To liaise with the PCN members, GPs, practice
managers, social prescribing link workers, health wellbeing coaches, MHICS,
social services, community nurses, nursing homes and primary care professionals
in order to coordinate personalised patient care
To be a point of contact for patients,
supporting them to manage their needs through answering queries, booking and
managing appointments and ensuring that they have they are able to make
informed choices about their care.
To coordinate internal educational events and
meetings for the clinical team, liaising with external contacts
About us
We
are Surrey Heath Community Providers Limited, which is a federation of 7 GP
practices across 10 sites, covering a population of over 97,000 patients across
Surrey Heath.
As a
GP Federation, we are proud to represent our member practices and to champion
primary care by working with local general practice and system partners in the
provision of community-based healthcare services. We are dedicated to providing
safe and compassionate care to our patients across our range of primary care
and unplanned healthcare services in Surrey Heath, and believe in continuous
commitment to quality service delivery and positive patient outcomes.
Patients are at the heart of
everything we do, and we pride ourselves in ensuring our patients feel safe, supported, communicated with and
respected, at a time when they may be feeling vulnerable. Our vision is to
provide high quality, seamless health care that enables people to lead
healthier lives, whilst feeling supported and cared for.
Job description
Job responsibilities
Provide
coordination and navigation for people and their carers across health and
care services, working closely with social prescribers, health and wellbeing
coaches and other primary care professionals.
Utilise population
health intelligence to proactively identify and work with a cohort of
patients to deliver personalised care
Support PCN
staff and patients to be prepared to have shared-decision making
conversations including utilising decision aids and tools, and support
patients 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.
Help people to
manage their needs through answering queries, making and managing
appointments and ensuring that people have food quality written or verbal
information to help them make choices about their care
Support the
practice with the Patient Participation Group [PPG]
Holistically
bring together all of a persons identified care and support plan, in line
with best practice, based on what matters to the person
Support people
to take up training and employment, and to access appropriate benefits,
education courses, peer support, and/or personal health budgets where
applicable
Raise awareness
within the PCN of shared-decision making and decision support tools,
including how to identify patients who may benefit from this
As part of the
multidisciplinary team, build relationships with staff in GP practices within
the PCN, attending relevant meetings, providing information and feedback on
care coordination priorities
Be proactive in
developing strong link with local agencies, and in encouraging equality and
inclusions
Liaise directly
with care homes and other key providers, and compile and circulate relevant
information across stakeholder groups
Understand, out
in place and adhere to safeguarding protocols for vulnerable individuals
Capture key
information to enable comprehensive and accurate records of support,
inputting these into clinical systems as required and adhering to data
protection legislation
Job description
Job responsibilities
Provide
coordination and navigation for people and their carers across health and
care services, working closely with social prescribers, health and wellbeing
coaches and other primary care professionals.
Utilise population
health intelligence to proactively identify and work with a cohort of
patients to deliver personalised care
Support PCN
staff and patients to be prepared to have shared-decision making
conversations including utilising decision aids and tools, and support
patients 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.
Help people to
manage their needs through answering queries, making and managing
appointments and ensuring that people have food quality written or verbal
information to help them make choices about their care
Support the
practice with the Patient Participation Group [PPG]
Holistically
bring together all of a persons identified care and support plan, in line
with best practice, based on what matters to the person
Support people
to take up training and employment, and to access appropriate benefits,
education courses, peer support, and/or personal health budgets where
applicable
Raise awareness
within the PCN of shared-decision making and decision support tools,
including how to identify patients who may benefit from this
As part of the
multidisciplinary team, build relationships with staff in GP practices within
the PCN, attending relevant meetings, providing information and feedback on
care coordination priorities
Be proactive in
developing strong link with local agencies, and in encouraging equality and
inclusions
Liaise directly
with care homes and other key providers, and compile and circulate relevant
information across stakeholder groups
Understand, out
in place and adhere to safeguarding protocols for vulnerable individuals
Capture key
information to enable comprehensive and accurate records of support,
inputting these into clinical systems as required and adhering to data
protection legislation
Person Specification
Qualifications
Essential
- Educated to GCSE level or equivalent
Desirable
- Desirable if hold a relevant NVQ Level 3 qualification or equivalent
Skills
Essential
- Experience of working with healthcare professionals and/or previous experience in the NHS or social care
- Experience coordinating with multiple stakeholder or individuals to meet specified outcomes
- Experience providing advice/signposting
- Experience using a patient clinical system such as EMIS
- Awareness of how and when to signpost
- Knowledge of safeguarding interventions and an awareness of the Mental Capacity Act
- Skilled in the use of person-centred measurement and outcomes delivery
- Excellent verbal communication skills with the ability to communicate effectively at all levels including with patients, carers, specialist services, GPs and colleagues.
- Good technical literacy with e.g. Word, Excel, and experience using a clinical system such as EMIS
- Able to work independently and manage own workload
- Able to build strong professional relationships
- Demonstrable experience of effective planning and organisation skills to deliver targets to deadlines
- Proven record of excellent written communication skills and a high level of health literacy
- Understanding of social determinants of health and how these can be addressed with patients
- Able to analyse and interpret information and present results in a clear and concise manner
Desirable
- Knowledge of a range of local community groups which support wellbeing (desirable)
- Awareness of relevant Health and Social Care legislation and a developed knowledge of crisis intervention (desirable)
- Experience of undertaking quality improvement activity (desirable)
- Sound understanding of disease prevention and the NHS choices website (desirable)
Person Specification
Qualifications
Essential
- Educated to GCSE level or equivalent
Desirable
- Desirable if hold a relevant NVQ Level 3 qualification or equivalent
Skills
Essential
- Experience of working with healthcare professionals and/or previous experience in the NHS or social care
- Experience coordinating with multiple stakeholder or individuals to meet specified outcomes
- Experience providing advice/signposting
- Experience using a patient clinical system such as EMIS
- Awareness of how and when to signpost
- Knowledge of safeguarding interventions and an awareness of the Mental Capacity Act
- Skilled in the use of person-centred measurement and outcomes delivery
- Excellent verbal communication skills with the ability to communicate effectively at all levels including with patients, carers, specialist services, GPs and colleagues.
- Good technical literacy with e.g. Word, Excel, and experience using a clinical system such as EMIS
- Able to work independently and manage own workload
- Able to build strong professional relationships
- Demonstrable experience of effective planning and organisation skills to deliver targets to deadlines
- Proven record of excellent written communication skills and a high level of health literacy
- Understanding of social determinants of health and how these can be addressed with patients
- Able to analyse and interpret information and present results in a clear and concise manner
Desirable
- Knowledge of a range of local community groups which support wellbeing (desirable)
- Awareness of relevant Health and Social Care legislation and a developed knowledge of crisis intervention (desirable)
- Experience of undertaking quality improvement activity (desirable)
- Sound understanding of disease prevention and the NHS choices website (desirable)
