Job summary
This role is to
support the smooth co-ordination of patient care for one practice within the
Primary Care Network for the benefit of our patients.
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.
Main duties of the job
- To work at one base within a Primary Care Network.
- 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.
- 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.
- To talk to
patients, and where appropriate their families and/or carers, on the practice
premises, remotely by telephone or video, or in the patients home if needed.
- Liaise with Care
Homes as necessary.
About us
Alliance for Better Care CIC is a GP Federation
that unites 47 NHS GP practices across 12 Primary Care Networks in Sussex and
Surrey. We support our Primary Care colleagues as well as their patients, to
transform how healthcare is managed within the community.
As a membership organisation, our focus is to work in partnership with our
members and help them to improve the provision of General Practices in the
local area.
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.
Haywards Heath Central Primary Care Network is a NHS
Collaboration between two GP Practices Dolphins Practice and Newtons Practice
- working together to provide enhanced access services.
Our surgery teams work closely, sharing expertise and
resources to develop new services. Our vision is to continue to improve the
quality of care that we provide in alignment with the needs of our patient
population.
Our PCN builds on the existing primary care
services and enables a greater provision of proactive, personalised and more
integrated health and social care. We are supported by practitioners in
additional roles who allow us to create bespoke multi-disciplinary teams based
on the needs of our local population.
Job description
Job responsibilities
MDT
Coordination
- 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.
- Identify patients
to discuss at PCN level MDTs with a view to reducing unplanned admissions and
exacerbation of conditions.
Managing
a caseload
- Identify patients
that may need support by receiving information about transfers of care
(including hospital admissions and discharges) and from internal practice
intelligence.
- 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.
- Help patients
understand their condition by liaising with clinical colleagues, especially the
practice pharmacy team, regarding their medication. Aim for patients to have
specific instructions regarding their medication and understand how they access
repeat prescriptions and reviews.
- 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.
- Promote clear
communication amongst a care team and treating clinicians by ensuring awareness
regarding patient care plans.
- Assist and empower
the patient to consult and collaborate with other health care providers and
specialists to set up patient appointments and treatment plans.
- Check in on the
patient regularly and evaluate and document their progress.
Linking with other services
- Signpost team
members, service users and carers to relevant services including the PCN Social
Prescribing Link Worker Service.
- Liaise with the Social Prescriber and Mental
Health Support Coordinator regarding patients that are identified as needing
well-being support.
- Liaise with practice clinicians responsible
for frailty regarding patients that are identified as needing ongoing support.
- Liaise with acute trusts, care homes,
hospices, community and social care providers as required.
Record
Keeping
- Keep accurate and
up-to-date records of contact with patients, carers and professionals,
including use of SystmOne to record patient contact on the medical record.
- Use accurate SNOMED codes to record patient
contacts and interventions, mainly via the use of provided templates, for audit
purposes and monitoring and measuring outcomes.
- Manage reporting required and associated
within the DES specifications for required services.
- Report case studies and outcomes to the PCN on
a quarterly basis.
General
Responsibilities
- 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.
- Attend ongoing
training and courses to keep abreast of new developments in health care.
- Treat patients with
empathy and respect and conduct oneself in a professional manner.
- Attend and
contribute to relevant meetings.
- 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
MDT
Coordination
- 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.
- Identify patients
to discuss at PCN level MDTs with a view to reducing unplanned admissions and
exacerbation of conditions.
Managing
a caseload
- Identify patients
that may need support by receiving information about transfers of care
(including hospital admissions and discharges) and from internal practice
intelligence.
- 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.
- Help patients
understand their condition by liaising with clinical colleagues, especially the
practice pharmacy team, regarding their medication. Aim for patients to have
specific instructions regarding their medication and understand how they access
repeat prescriptions and reviews.
- 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.
- Promote clear
communication amongst a care team and treating clinicians by ensuring awareness
regarding patient care plans.
- Assist and empower
the patient to consult and collaborate with other health care providers and
specialists to set up patient appointments and treatment plans.
- Check in on the
patient regularly and evaluate and document their progress.
Linking with other services
- Signpost team
members, service users and carers to relevant services including the PCN Social
Prescribing Link Worker Service.
- Liaise with the Social Prescriber and Mental
Health Support Coordinator regarding patients that are identified as needing
well-being support.
- Liaise with practice clinicians responsible
for frailty regarding patients that are identified as needing ongoing support.
- Liaise with acute trusts, care homes,
hospices, community and social care providers as required.
Record
Keeping
- Keep accurate and
up-to-date records of contact with patients, carers and professionals,
including use of SystmOne to record patient contact on the medical record.
- Use accurate SNOMED codes to record patient
contacts and interventions, mainly via the use of provided templates, for audit
purposes and monitoring and measuring outcomes.
- Manage reporting required and associated
within the DES specifications for required services.
- Report case studies and outcomes to the PCN on
a quarterly basis.
General
Responsibilities
- 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.
- Attend ongoing
training and courses to keep abreast of new developments in health care.
- Treat patients with
empathy and respect and conduct oneself in a professional manner.
- Attend and
contribute to relevant meetings.
- 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
Knowledge & Experience
Essential
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
- Experience of working directly in either the NHS or Adult Social Care
Qualifications
Essential
- Demonstrable commitment to professional and personal development with a can do attitude.
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards
- Training in motivational coaching and interviewing or equivalent experience
Behaviours & Values
Essential
- Able to work flexibly and enthusiastically within a team or on own initiative
Skills & Abilities
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
Desirable
- Excellent IT skills including Excel as well as knowledge of GP clinical systems, experience of data entry and coding
Person Specification
Knowledge & Experience
Essential
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
- Experience of working directly in either the NHS or Adult Social Care
Qualifications
Essential
- Demonstrable commitment to professional and personal development with a can do attitude.
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards
- Training in motivational coaching and interviewing or equivalent experience
Behaviours & Values
Essential
- Able to work flexibly and enthusiastically within a team or on own initiative
Skills & Abilities
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
Desirable
- Excellent IT skills including Excel as well as knowledge of GP clinical systems, experience of data entry and coding
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.
