Job summary
The PCN
are looking for a Care Coordinator to support the smooth co-ordination of care
across the Care Collaborative Primary Care Network.
The Coordinator will support the Link Worker
Coordinator in identifying and managing a caseload of patients, referring
patients to health and social professionals as needed and providing and
organising PCN Multi-Disciplinary Team Meeting on a regular basis.
Main duties of the job
- To work across a Primary Care Network supporting a wide range of patients of all ages living within Care Homes and living independently (Residential, Nursing, Learning Disability)
- To utilise soft and hard intelligence within the PCN to identify patients who will benefit from a proactive approach by the PCN, the wider community and multidisciplinary teams
- Identifying patients to discuss at PCN level MDTs where a multiple professional group attend to discuss the most complex patients, in a view to reducing unplanned admissions and exacerbation of conditions
- Coordinate weekly MDT meetings within the PCNs, alongside the Link Worker Coordinators and supporting the running of MDTs independently when the Link Workers are on leave ensuring that relevant professionals are in attendance, either face to face or by dial in remotely
About us
Alliance for Better Care CIC is a pro-active, forward-thinking GP federation that unites 47 GP practices across 12 Primary Care Networks in Surrey and Sussex. We support our primary care colleagues to transform how healthcare is managed within the community.
Our strength lies not just in our ability to connect all areas of primary care, but also in the way we support and strengthen the role primary care plays in the rest of the system. We are the glue that helps bind them together.
We work with and listen to our GP practices, PCNs, hospitals, community organisations and the third sector. These vital partnerships ensure that, together, we deliver a truly integrated approach that offers the support and expertise needed to effectively serve our communities. As a membership organisation, we have the ability to share our expertise at scale, and were happy to do so.
ABC provide employment and management support to the Care Collaborative Primary Care Network comprising the following practices:
- The Wall House Surgery
- Greystone House Surgery
- Moat House Surgery
Job description
Job responsibilities
Key responsibilities and Duties:
- Uploading and maintaining patient care plans to EMIS and other relevant systems as necessary
- Maintaining action logs to audit outcomes and being able to give updates to professionals from multiple providers across the PCN, including the patients, carers and next of kin
- Ensuring all Care Homes within the PCN have a weekly check in. Phoning patients in their own homes regularly who have been identified as needing clinical and social support
- Identifying patients with and without care plans, to ensure they are up to date and shared with other agencies including the ambulance service
- Keeping up to date records in all GP clinical systems across the PCN, including data that can be reported on and shared with the PCN for outcomes, on a monthly basis
- Maintaining action logs to audit outcomes and being able to give updates to professionals from multiple providers across the PCN, including the patients, carers and next of kin
- Arranging GP ward rounds to Care Homes
- Liaising with Acute Trusts, Hospices, Community and Social Care providers as required
- Liaising with the Link Worker Social Prescriber for patients that are identified as needing well- being support
- Ensuring Templates are completed by professionals in order to provide accurate data, by encouraging there use and auditing regularly to ensure adherence
- To support the Link Worker Co-Ordinator to Collate monthly data from each Practice within each PCN. To work with the ABC Data Analyst to compile monthly data that can be shared with the PCNs and the CCG
- Supporting the Link Worker Co-Ordinator with their daily activities
Record Keeping and General Responsibilities
- To keep accurate and up-to-date records of their contact with patients, carers and professionals, including the use of GP databases such as EMIS/System One
- To use read codes to tag those patients identified for interventions and must be placed on the patient’s record, so that activity and metrics associated with these patients can be tracked over time by the PCN to monitor outcomes and provide data for ‘proof of concept’
- To collect data in a prescribed format as required, in order to demonstrate the impact of the service
- To actively engage with the practice teams within the PCN, ensure effective liaison with all PCN staff and contribute to the overall aims of the PCN
- To attend and contribute to relevant meetings
Miscellaneous
- Work as part of the team to seek feedback, continually improve the service and contribute to business planning
- Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner
- Duties may vary from time to time, without changing the general character of the post or the level of responsibility
Please see the full Job Description for further information.
Job description
Job responsibilities
Key responsibilities and Duties:
- Uploading and maintaining patient care plans to EMIS and other relevant systems as necessary
- Maintaining action logs to audit outcomes and being able to give updates to professionals from multiple providers across the PCN, including the patients, carers and next of kin
- Ensuring all Care Homes within the PCN have a weekly check in. Phoning patients in their own homes regularly who have been identified as needing clinical and social support
- Identifying patients with and without care plans, to ensure they are up to date and shared with other agencies including the ambulance service
- Keeping up to date records in all GP clinical systems across the PCN, including data that can be reported on and shared with the PCN for outcomes, on a monthly basis
- Maintaining action logs to audit outcomes and being able to give updates to professionals from multiple providers across the PCN, including the patients, carers and next of kin
- Arranging GP ward rounds to Care Homes
- Liaising with Acute Trusts, Hospices, Community and Social Care providers as required
- Liaising with the Link Worker Social Prescriber for patients that are identified as needing well- being support
- Ensuring Templates are completed by professionals in order to provide accurate data, by encouraging there use and auditing regularly to ensure adherence
- To support the Link Worker Co-Ordinator to Collate monthly data from each Practice within each PCN. To work with the ABC Data Analyst to compile monthly data that can be shared with the PCNs and the CCG
- Supporting the Link Worker Co-Ordinator with their daily activities
Record Keeping and General Responsibilities
- To keep accurate and up-to-date records of their contact with patients, carers and professionals, including the use of GP databases such as EMIS/System One
- To use read codes to tag those patients identified for interventions and must be placed on the patient’s record, so that activity and metrics associated with these patients can be tracked over time by the PCN to monitor outcomes and provide data for ‘proof of concept’
- To collect data in a prescribed format as required, in order to demonstrate the impact of the service
- To actively engage with the practice teams within the PCN, ensure effective liaison with all PCN staff and contribute to the overall aims of the PCN
- To attend and contribute to relevant meetings
Miscellaneous
- Work as part of the team to seek feedback, continually improve the service and contribute to business planning
- Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner
- Duties may vary from time to time, without changing the general character of the post or the level of responsibility
Please see the full Job Description for further information.
Person Specification
Qualifications
Essential
- Demonstrable commitment to professional and personal development.
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards.
- Training in motivational coaching and interviewing or equivalent experience.
Experience
Desirable
- Experience of working directly in either the NHS or Adult Social Care.
Personal Qualities & Attributes
Essential
- Able to listen, empathise with people and provide person- centred support in a non-judgemental way.
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Committed to reducing health inequalities and proactively working to reach people from all communities.
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Able to identify risk and assess/manage risk when working with individuals.
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.
Knowledge & Skills
Essential
- Excellent IT skills including Excel, knowledge of GP systems.
- Able to provide leadership and to finish work tasks.
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues.
- Commitment to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues.
- Demonstrates personal accountability, emotional resilience and works well under pressure.
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
- High level of written and oral communication skills.
- Ability to work flexibly and enthusiastically within a team or on own initiative.
- Understanding of the needs of small volunteer-led community groups and ability to support their development.
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
Person Specification
Qualifications
Essential
- Demonstrable commitment to professional and personal development.
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards.
- Training in motivational coaching and interviewing or equivalent experience.
Experience
Desirable
- Experience of working directly in either the NHS or Adult Social Care.
Personal Qualities & Attributes
Essential
- Able to listen, empathise with people and provide person- centred support in a non-judgemental way.
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Committed to reducing health inequalities and proactively working to reach people from all communities.
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Able to identify risk and assess/manage risk when working with individuals.
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.
Knowledge & Skills
Essential
- Excellent IT skills including Excel, knowledge of GP systems.
- Able to provide leadership and to finish work tasks.
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues.
- Commitment to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues.
- Demonstrates personal accountability, emotional resilience and works well under pressure.
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
- High level of written and oral communication skills.
- Ability to work flexibly and enthusiastically within a team or on own initiative.
- Understanding of the needs of small volunteer-led community groups and ability to support their development.
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
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.