Job summary
This is an exciting opportunity for a Care Coordinator to join the Horley Primary Care Network. This role is to support the smooth
co-ordination of care across the Horley Primary Care Network.
The Coordinator will support the PCN
Anticipatory Care Hub 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.
This is a part time, fixed term post until 31st March 2024.
Main duties of the job
Supporting a wide range of patients of all
ages – living within Care Homes and living independently (Residential, Nursing,
Learning Disability)
Utilising 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
Coordinating and supporting the running of the weekly
MDT meetings. Ensuring that relevant professionals are in attendance, either
face to face or by dialling in remotely
About us
ABC is a not-for-profit organisation that is proud to support the sustainability and success of General Practice in East Surrey, Crawley, Horsham and Mid-Sussex. We represent more than 40 GP practices in the region and work alongside local CCGs to develop a larger primary care and integrated workforce. Together our aim is to meet the increasing physical health, mental health and social care needs of more than half a million residents.
The organisation is built on the belief that successful General Practice is fundamental to improving the health and happiness of our communities.
ABC provide employment and management support to the Horley Primary Care Network comprising the following practices:
- Smallfield Surgery
- Birchwood Medical Practice
- Wayside Surgery
Job description
Job responsibilities
- 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
Ensuring Templates are completed by
professionals in order to provide accurate data, by encouraging there use and
auditing regularly to ensure adherence
- 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
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
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 full Job Description.
Job description
Job responsibilities
- 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
Ensuring Templates are completed by
professionals in order to provide accurate data, by encouraging there use and
auditing regularly to ensure adherence
- 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
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
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 full Job Description.
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
Essential
- Experience of working directly in either the NHS or Adult Social Care
Personal Qualities & Attributes
Essential
- Ability 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
- Commitment 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
- 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
- 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
- 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
Essential
- Experience of working directly in either the NHS or Adult Social Care
Personal Qualities & Attributes
Essential
- Ability 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
- Commitment 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
- 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
- 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
- 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.
