Care Coordinator - Crawley Care Collaborative PCN

Alliance for Better Care Ltd.

Information:

This job is now closed

Job summary

The PCN are looking for a Care Coordinator that will work at one of the network practices (Langley Corner Surgery), as well as time dedicated to training and networking.

Full time hours - 37.5 hours per week

This is a fixed term contract until 31st March 2024.

Main duties of the job

This role is to support the smooth co-ordination of patient care across the Crawley Care Collaborative Primary Care Network for the benefit of our patients. The post holder will join a team of PCN Care Coordinators.

The Care Coordinator will be responsible for consulting with patients and determining their needs, developing care plans, coordinating patient-care services, educating them about their condition, empowering them to be independent whenever possible and working with the care team to evaluate interventions.

This role will be expected to heavily support the practice to reach its targets for their Enhanced Services and Quality Outcome Framework (QOF).This role will need to support (where necessary) all additional projects led by NHSE or CCG which will support the need and care of the practices patient list.

About us

Alliance for Better Care Ltd (ABC) is the federation of the 44 East Surrey, Crawley Horsham and Mid Sussex GP practices, established in 2014, and now comprising twelve Primary Care Networks. ABC provide employment and management support to the Crawley Care Collaborative Primary Care Network comprising the following practices:

  • Bridge Medical Centre
  • Langley Corner Surgery
  • Leacroft Medical Practice
  • Southgate Medical Group

Date posted

20 July 2022

Pay scheme

Other

Salary

£22,607.47 to £23,991.23 a year

Contract

Fixed term

Duration

2 years

Working pattern

Full-time

Reference number

B0141-22-9924

Job locations

Langley Corner Surgery

Ifield Green

Ifield

Crawley

West Sussex

RH11 0NF


Job description

Job responsibilities

Key Responsibilities and Duties

1. To work across a Primary Care Network.

2. To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence.

3. To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patient’s home if needed.

4. Support the practice to reach its targets for their Enhanced Services and Quality Outcome Framework (QOF).

MDT Coordination

1. Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting.

2. Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions.

Managing a caseload

1. Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence.

2. Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication and give them specific instructions.

3. Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacists, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews.

4. With the help of relevant clinical colleagues, develop a care plan to address patients’ personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare.

5. Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.

6. Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans.

7. Check in on the patient regularly and evaluate and document their progress.

Please see full Job Description for further information.

Job description

Job responsibilities

Key Responsibilities and Duties

1. To work across a Primary Care Network.

2. To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence.

3. To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patient’s home if needed.

4. Support the practice to reach its targets for their Enhanced Services and Quality Outcome Framework (QOF).

MDT Coordination

1. Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting.

2. Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions.

Managing a caseload

1. Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence.

2. Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication and give them specific instructions.

3. Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacists, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews.

4. With the help of relevant clinical colleagues, develop a care plan to address patients’ personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare.

5. Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.

6. Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans.

7. Check in on the patient regularly and evaluate and document their progress.

Please see 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.
  • Able to provide leadership and to finish work tasks.
  • Able to maintain effective working relationships and to promote collaborative practice with all colleagues.
  • Committed 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.
  • Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
  • High level of written and oral communication skills.
  • Able to work flexibly and enthusiastically within a team or on own initiative.
  • Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.

Desirable

  • Excellent IT skills including Excel and knowledge of GP clinical systems.
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.
  • Able to provide leadership and to finish work tasks.
  • Able to maintain effective working relationships and to promote collaborative practice with all colleagues.
  • Committed 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.
  • Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
  • High level of written and oral communication skills.
  • Able to work flexibly and enthusiastically within a team or on own initiative.
  • Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.

Desirable

  • Excellent IT skills including Excel and knowledge of GP clinical systems.

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

Alliance for Better Care Ltd.

Address

Langley Corner Surgery

Ifield Green

Ifield

Crawley

West Sussex

RH11 0NF


Employer's website

https://abcltd.org.uk/ (Opens in a new tab)

Employer details

Employer name

Alliance for Better Care Ltd.

Address

Langley Corner Surgery

Ifield Green

Ifield

Crawley

West Sussex

RH11 0NF


Employer's website

https://abcltd.org.uk/ (Opens in a new tab)

For questions about the job, contact:

Lena Abdu

lena.abdu@nhs.net

Date posted

20 July 2022

Pay scheme

Other

Salary

£22,607.47 to £23,991.23 a year

Contract

Fixed term

Duration

2 years

Working pattern

Full-time

Reference number

B0141-22-9924

Job locations

Langley Corner Surgery

Ifield Green

Ifield

Crawley

West Sussex

RH11 0NF


Supporting documents

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