Primary Care Network Care Coordinator

Job description

Job responsibilities

Key Responsibilities and Duties:

The Care Coordinator will undertake work in line with PCN and directed priorities. The following are the core responsibilities of the role:

Clinical Pharmacy Support

Use clinical system risk stratification tools and Ardens Manger to identify and call/recall patients for the Clinical Pharmacy Team to review. This includes, but is not limited to, patients for:

Structured Medication Reviews

QOF Quality Improvement indicators

QOF Medicines indicators

IIF Medicines indicators

Practice Prescribing Schemes

Audits

Early Cancer Diagnosis

Support the delivery of PCN objectives under the Early Cancer Diagnosis requirements of the PCN DES. This includes but is not limited to:

Attending Cancer Steering Group meetings

Patient follow-up from cancer screening

Cancer care planning

Patient communications

Enhanced Care in Care Homes

You will:

Support the practice team to identify gaps in existing care plans and help produce and annual Personalised Care and Support Plan (PCSP), referring to the patients named GP to complete.

Liaise with care homes to schedule the monthly Clinical Pharmacist visits.

Liaise with care homes to ensure new admissions and patients who have been discharged from hospital, are reviewed at the next Ward Round, and have an updated PCSP.

Cardiovascular Disease Prevention and Diagnosis

Support patient call and recall as directed by the Senior Network Manager.

Health Inequalities

Identify patient cohorts being targeted by the PCN health inequalities steering group, inviting them to participate in agreed interventions.

Learning disabilities care planning.

Supporting patients & Social Prescribing:

Actively sign-post patients to a variety of services including Social Prescribing, making referrals as appropriate.

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

Information Technology

Write searches to identify target patient cohorts.

Write and update templates and protocols to effectively capture relevant clinical and non-clinical information.

Multi-Disciplinary Team (MDT) Meetings

Prepare agendas for MDT meetings and contact all parties to ensure attendance and to confirm patients to be discussed.

Care Planning

Support the practice objectives (local and PCN-level) to ensure care plans are actively created and updated. This includes for learning disability patients, dementia patients, care home residents and cancer patients.

Identify patients without recent care plans in place and work with their name GP to update these plans.

Ensure that preventative actions are agreed and detailed in care plans to support the reduction of unnecessary hospital admissions.

Investment and Impact Fund (IIF)

Support patient call and recall as directed by the Senior Network Manager.

Ensure the minimum number of patient contacts by aligning multiple tests and reviews.

Support Data Collection:

Ensure timely and accurate collation of data for the PCN

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

Validate and quality assure incoming data.

Run regular patient searches using clinical systems to have an up-to-date record of progress of achievement of Key Performance Indicators (KPIs).

Case finding to support target achievement and enhancing register prevalence.

PCN Duties

Provide an agreed Care Coordinator service to all PCN practices with duties to be defined by the PCN managers.

Person Specification

Qualifications

Essential

• Good standard of education with excellent literacy and numeracy skills

Desirable

• NVQ Level 3 Business Administration (or relevant experience)

Experience

Essential

• Experience of working in General Practice, the NHS or Social Care
• Understanding of current issues facing the NHS and social care process
• Experience of administrative duties
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality
• Working in a multi-disciplinary setting where influence and negotiation is required
• Working in a busy and demanding environment whilst delivering in a timely manner

Desirable

• Knowledge/familiarity with medical terminology
• Previous experience in the Care Coordinator role.

Skills

Essential

• Proven record of excellent written skills and verbal communication skills and interpersonal skills
• Evidence of excellent knowledge of Microsoft Office
• Able to work as part of a team
• Excellent motivational and influencing skills
• Able to prioritise and manage own workload and ensuring completion of tasks on time
• Strong analytical and judgement skills
• Ability to analyse and interpret information and present results in a clear and concise manner

Desirable

• Experience working with EMIS Web, Medical record system
• Able to effectively influence others to complete agreed actions

Personal Qualities

Essential

• Professional attitude, calm and efficient manner
• Conscientious, hardworking, self- motivated, work with minimal supervision
• Creative and tenacious in finding solutions to difficult problems
• Ability to work with both clinical and administrative staff
• Ability to meet deadlines and work under pressure
• Ability to engage and sustain relationships with all professionals, other organisations and service-users
• Honest, reliable and enthusiastic, has a flexible approach
• Committed to personal development, willingness to undergo further training or development
• Car user and willing to travel between PCN GP practices

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

Bolton GP Federation

Address

Floor 2, The Hub

Bold Street

Bolton

Lancashire

BL1 1LS

Employer's website

http://www.boltongpfed.co.uk/ (Opens in a new tab)