Job summary
At
Horsham Central PCN, care coordinators are pivotal to improving the quality of
care and operational efficiencies and so requires motivation, passion and
innovative thinking to deliver an excellent service.
Our
care coordinators will work within their own scope of practice, led by the PCN
Management team and within a multi-disciplinary team to provide expertise in
coordinating key activity, quality data reporting and helping to implement
efficient well led services to ensure health and care planning according to the
needs of our community.
This
role will be adding to a well-established team comprising of clinical,
non-clinical and allied health professionals.
Main duties of the job
The
post holder will work within the PCN Team, providing coordination, and
administrative support to the Clinical teams and other members of the PCN.
The
post holder will work closely with Care Homes, General Practices and existing
services to support the coordination and delivery of multidisciplinary team
meetings for care home residents.
The
post holder will support the PCN to proactively identify residents in care
homes who require a personalised care and support plan
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:
- Park
Surgery
- Holbrook
Surgery
- Orchard
Surgery
- Riverside
Surgery
Job description
Job responsibilities
The
post holder will work within the PCN Team, providing coordination, and
administrative support to the Clinical teams and other members of the PCN.
The
post holder will work closely with Care Homes, General Practices and existing
services to support the coordination and delivery of multidisciplinary team
meetings for care home residents.
The
post holder will support the PCN to proactively identify residents in care
homes who require a personalised care and support plan
The
post holder, working closely with the PCN team, Care Home, GPs and existing
community services will:
- Coordinate
Multi-Disciplinary Team meetings for people living in care homes
- Utilise
Population Health Intelligence to proactively identify care home residents and
work with the PCN team to enable the PCN team to deliver personalised care
- Utilise
Population Health Intelligence tools where needed to support other patients in
the PCN.
- Establish
good working relationships with people employed in our member practices
- Utilise
population health intelligence to proactively identify cohorts of patients to
deliver services and care specific to the needs of our population. Use Ardens
and other appropriate population health dashboards and tools to help deliver
the population health management projects.
- Carry
out audits to identify improvement and enhance services
- Work
across practices to share good practice, identify information/training needs,
and implement effective systems and training.
- Raise
awareness within the PCN of shared-decision making and decision support tools
- Design
efficient templates, protocols, alerts and other tools as appropriate to
support safety, patient care, quality record-keeping, reporting and financial
claims.
- To
liaise closely with Patient Engagement and Comms. Lead to effectively
communicate with members of the public/practice staff and PCN team members
- Work
closely with CCO Lead and management team on ad hoc projects relating to
patient and staff education
- Work
closely with Clinical Operations Lead to support and ensure delivery of Impact
and Investment Fund Indicators
- Support
the delivery of national and local vaccination programmes.
Job description
Job responsibilities
The
post holder will work within the PCN Team, providing coordination, and
administrative support to the Clinical teams and other members of the PCN.
The
post holder will work closely with Care Homes, General Practices and existing
services to support the coordination and delivery of multidisciplinary team
meetings for care home residents.
The
post holder will support the PCN to proactively identify residents in care
homes who require a personalised care and support plan
The
post holder, working closely with the PCN team, Care Home, GPs and existing
community services will:
- Coordinate
Multi-Disciplinary Team meetings for people living in care homes
- Utilise
Population Health Intelligence to proactively identify care home residents and
work with the PCN team to enable the PCN team to deliver personalised care
- Utilise
Population Health Intelligence tools where needed to support other patients in
the PCN.
- Establish
good working relationships with people employed in our member practices
- Utilise
population health intelligence to proactively identify cohorts of patients to
deliver services and care specific to the needs of our population. Use Ardens
and other appropriate population health dashboards and tools to help deliver
the population health management projects.
- Carry
out audits to identify improvement and enhance services
- Work
across practices to share good practice, identify information/training needs,
and implement effective systems and training.
- Raise
awareness within the PCN of shared-decision making and decision support tools
- Design
efficient templates, protocols, alerts and other tools as appropriate to
support safety, patient care, quality record-keeping, reporting and financial
claims.
- To
liaise closely with Patient Engagement and Comms. Lead to effectively
communicate with members of the public/practice staff and PCN team members
- Work
closely with CCO Lead and management team on ad hoc projects relating to
patient and staff education
- Work
closely with Clinical Operations Lead to support and ensure delivery of Impact
and Investment Fund Indicators
- Support
the delivery of national and local vaccination programmes.
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- centered 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- centered 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.
