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PCN - Care Coordinator

Waltham Forest Federated GP Network

The closing date is 15 March 2025

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Job summary

An exciting opportunity has arisen for a Care Coordinator in the organisation, who must be available to work on a full-time basis with flexibility when required to work across sites within PCNs. Practices across Waltham Forest have come to work collaboratively as Primary Care Networks (PCNs), pooling their resources and workforce to provide improved and integrated services for their patients. PCNs typically consist of 30,000-50,000 patients.

Main duties of the job

Work within our network of GP Practices to provide a central co-ordination role for patient care planning. The role will be GP facing, with the core responsibility being excellent patient care.

Co-ordinate care packages for patients as identified by the GP across health, social care and mental health as appropriate, providing a single-point of access for staff & service users, actively managing patients care plan delivery

Facilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support

Identify and work with a list of named patients with the aim of encouraging independence, enabling people to remain at home, reducing unnecessary admissions to hospitals and supporting early discharge from hospital, improving the quality of care.

About us

WF GP FedNet is a not-for-profit Federation of 36 GP Practices in Waltham Forest. We are a private limited company who provides NHS Services based in Primary Care, pooling the skills and resources of local GPs to provide large scale services as part of the local NHS Strategy to bring more services into the Community to help people stay well and at home

Date posted

26 February 2025

Pay scheme

Agenda for change

Band

Band 4

Salary

£31,081 a year Salary includes High cost area supplements (HCAS)

Contract

Fixed term

Duration

12 months

Working pattern

Full-time

Reference number

B0116-25-0007

Job locations

500 Larkshall Road

Highams Park

London

E4 9HH


Job description

Job responsibilities

Job responsibilities

1. Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames

2. Explain the management of a patients pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms

3. Work closely with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated and of the patients care plan, without requiring a further referral from the GP.

4. Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame.

5. Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations communications & patient notes and ensuring care packages are set up

6. Collect data on patients/carers for recognised outcome measure and document for service interpretation. Ensure all patient notes are updated to reflect any changes, including details on plans

7. Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and lead the meetings. Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance

8. Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.

9. Network and develop strong relationships with all levels of the NHSs key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector

Be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders

Job description

Job responsibilities

Job responsibilities

1. Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames

2. Explain the management of a patients pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms

3. Work closely with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated and of the patients care plan, without requiring a further referral from the GP.

4. Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame.

5. Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations communications & patient notes and ensuring care packages are set up

6. Collect data on patients/carers for recognised outcome measure and document for service interpretation. Ensure all patient notes are updated to reflect any changes, including details on plans

7. Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and lead the meetings. Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance

8. Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.

9. Network and develop strong relationships with all levels of the NHSs key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector

Be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders

Person Specification

Qualifications

Essential

  • Relevant degree or equivalent level of training and experience
  • Evidence of a consistent pattern of learning from education, training and experience

Desirable

  • Qualification in health or social care allied profession
Person Specification

Qualifications

Essential

  • Relevant degree or equivalent level of training and experience
  • Evidence of a consistent pattern of learning from education, training and experience

Desirable

  • Qualification in health or social care allied profession

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

Waltham Forest Federated GP Network

Address

500 Larkshall Road

Highams Park

London

E4 9HH


Employer's website

https://wfgpfednet.co.uk/ (Opens in a new tab)

Employer details

Employer name

Waltham Forest Federated GP Network

Address

500 Larkshall Road

Highams Park

London

E4 9HH


Employer's website

https://wfgpfednet.co.uk/ (Opens in a new tab)

For questions about the job, contact:

Date posted

26 February 2025

Pay scheme

Agenda for change

Band

Band 4

Salary

£31,081 a year Salary includes High cost area supplements (HCAS)

Contract

Fixed term

Duration

12 months

Working pattern

Full-time

Reference number

B0116-25-0007

Job locations

500 Larkshall Road

Highams Park

London

E4 9HH


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