Job summary
This an exciting opportunity for a Care Coordinator to join the North Tandridge Primary Care Network.
This is a split role between
Anticipatory Care and the Children and Young People Social Prescribing Service,
and will support the smooth co-ordination of care across the North Tandridge Primary
Care Network.
The Care 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.
This post is until 31st March 2024.
Main duties of the job
- To work across a Primary Care Network supporting a wide range of patients of all ages within the Anticipatory Care Hub and those referred to the Children and Young People Social Prescribing Service alongside the Social Prescribing Link Worker for Children and Young People
- 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
Please see full Job Description for more information.
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 North Tandridge Primary Care Network comprising of the following practices:
- Caterham Valley Medical Practice
- Whyteleafe Surgery
- Townhill Medical Practice
- Chaldon Road Surgery
- Elizabeth House Medical Practice
- Warlingham Green Medical Practice
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
- 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 Coordinator 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 Coordinator with their daily activities.
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
- 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 Coordinator 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 Coordinator with their daily activities.
Person Specification
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
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
Person Specification
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
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
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.