Job summary
Are you an innovative person with excellent interpersonal and communication skills and would love the exciting challenge of working within a developing patient-focused service, consistently approaching patients with empathy, then this could be the job for you.
Population Health Management (PHM) care coordinator will work across their respective PCN to support the delivery of the Population Health Management Programme. This programme is focussed on providing more proactive support to people over 65 with mild/moderate frailty. This is an exciting time to join either Oldham South or Oldham North PCN in the progression and development of the Primary Care Networks and this pivotal role in delivering a pioneering health improvement programme. The role will involve supporting the ongoing identification, engagement and case management of over 65s with mild/moderate frailty, to intervene early to maintain good health, prevent deterioration and ensure they are able to access services which meet their range of needs. The role will work within one of the PCN teams and across an integrated neighbourhood team of different health and care professionals involved in the care of this group of patients to coordinate their care plans.
Main duties of the job
This role involves patient facing care, and the post holder will be responsible for providing support directly to patients and their carers. The post holder will also act as a conduit for patients within the PCN, liaising with GPs, district nurses, therapists, physios, adult social care, voluntary sector, and other PCN colleagues.
Actively develop effective working relationships and lines of communication within the practice, with the PCN, and with wider multi-professional teams across South e.g. Social Prescribers, Pharmacists and other clinical/non-clinical partners involve in the patients care
Demonstrates ability to work effectively as a member of a team with the practice, PCN and ANP as a key person within the PHM model.
Can recognise personal limitations and refer to more appropriate colleague(s) when necessary.
Follow through with service users and others involved to ensure all services and care arrangements are in place.
Develops an in-depth knowledge of local health and care infrastructure and knows how and when to enable people to access support and services that are right for them.
About us
Oldham South PCN and Oldham North PCN are looking to hire 2 full-time posts one in in each PCN.
Oldham South Primary Care Network (PCN) is a network of 5 GP Practices within the Oldham Integrated Care System. Oldham South PCN services a population of around 43,000 patients.
Oldham North Primary Care Network (PCN) is a network of 4 Practices within the Oldham Integrated Care System. Oldham North PCN services a population around 42,000 patients.
As PCNs, we are looking to grow our team of professionals focusing on a new population health management programme, to support more proactive and holistic care for people with mild to moderate frailty in our locality.
Job description
Job responsibilities
Main Duties and Responsibilities
Help people to manage their needs through answering queries, and ensuring that people have good quality written or verbal information to help them make choices about their care.
Own a list of potential patients across the PCN practices who are over 65 with mild and moderate frailty.
Contact patients on the list to enrol them in the programme and triage them into a pathway depending on their response to a questionnaire, working closely with an Advanced Nurse Practitioner.
Support the ongoing case management of patients on this pathway through regular check-ins and respond to any significant events (e.g. hospital admission), as well as supporting them to ensure their patient-centred care plan is regularly reviewed.
Work closely with multiple professionals from across the sectors to coordinate the patients care and ensure they are receiving the help and support they need.
Support the PCN on implementation of the programme by working within governance structures and providing feedback and iteration of the model.
Maintain a log that records the journey of each patient on the PHM programme, including the services they are referred to.
Identify where there may be health inequalities and provide feedback on where engagement could be enhanced.
Support improvement of information recording on patients across the PCN, including coding for these patients in EMIS and the Manchester Shared Care Record
Work closely with care coordinators across other Oldham PCNs e.g. South and North who are implementing PHM pathways focussed on frailty to support integration of care across organisational boundaries.
RESPONSIBILITIES TO PCN TEAMS
Actively develop effective working relationships and lines of communication within the practice, with the PCN, and with wider multi-professional teams across South e.g. Social Prescribers, Pharmacists and other clinical/non-clinical partners involve in the patients care
Demonstrates ability to work effectively as a member of a team with the practice, PCN and ANP as a key person within the PHM model.
Can recognise personal limitations and refer to more appropriate colleagues when necessary.
Follow through with service users and others involved to ensure all services and care arrangements are in place.
Develops an in-depth knowledge of local health and care infrastructure and knows how and when to enable people to access support and services that are right for them.
RESPONSIBILITIES TO PATIENTS
Manage a caseload of patients with mild and moderate frailty within the PCN.
Support patients to utilise decision aids in preparation for a shared decision-making conversation.
Proactively checks in with patients on the case load to help manage their needs through answering queries and ensuring that people have good quality written or verbal information to help them make choices about their care.
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing.
Job description
Job responsibilities
Main Duties and Responsibilities
Help people to manage their needs through answering queries, and ensuring that people have good quality written or verbal information to help them make choices about their care.
Own a list of potential patients across the PCN practices who are over 65 with mild and moderate frailty.
Contact patients on the list to enrol them in the programme and triage them into a pathway depending on their response to a questionnaire, working closely with an Advanced Nurse Practitioner.
Support the ongoing case management of patients on this pathway through regular check-ins and respond to any significant events (e.g. hospital admission), as well as supporting them to ensure their patient-centred care plan is regularly reviewed.
Work closely with multiple professionals from across the sectors to coordinate the patients care and ensure they are receiving the help and support they need.
Support the PCN on implementation of the programme by working within governance structures and providing feedback and iteration of the model.
Maintain a log that records the journey of each patient on the PHM programme, including the services they are referred to.
Identify where there may be health inequalities and provide feedback on where engagement could be enhanced.
Support improvement of information recording on patients across the PCN, including coding for these patients in EMIS and the Manchester Shared Care Record
Work closely with care coordinators across other Oldham PCNs e.g. South and North who are implementing PHM pathways focussed on frailty to support integration of care across organisational boundaries.
RESPONSIBILITIES TO PCN TEAMS
Actively develop effective working relationships and lines of communication within the practice, with the PCN, and with wider multi-professional teams across South e.g. Social Prescribers, Pharmacists and other clinical/non-clinical partners involve in the patients care
Demonstrates ability to work effectively as a member of a team with the practice, PCN and ANP as a key person within the PHM model.
Can recognise personal limitations and refer to more appropriate colleagues when necessary.
Follow through with service users and others involved to ensure all services and care arrangements are in place.
Develops an in-depth knowledge of local health and care infrastructure and knows how and when to enable people to access support and services that are right for them.
RESPONSIBILITIES TO PATIENTS
Manage a caseload of patients with mild and moderate frailty within the PCN.
Support patients to utilise decision aids in preparation for a shared decision-making conversation.
Proactively checks in with patients on the case load to help manage their needs through answering queries and ensuring that people have good quality written or verbal information to help them make choices about their care.
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing.
Person Specification
Qualifications
Essential
- Educated to GCSE Standard (Grades A-C) or Diploma/ HNC level (or relevant experience)
Experience
Essential
- Relevant health and social care experience at AfC Band 3 or 4 or equivalent and/or previous experience in the NHS or social care or relevant field
- Experience of administrative duties
- Experience within Primary Care.
Desirable
- Experience of working in Primary Care/Voluntary Sector/Community
-
- Experience in promoting health and health improvement within the community, including health
- Experience in Care Coordination
Person Specification
Qualifications
Essential
- Educated to GCSE Standard (Grades A-C) or Diploma/ HNC level (or relevant experience)
Experience
Essential
- Relevant health and social care experience at AfC Band 3 or 4 or equivalent and/or previous experience in the NHS or social care or relevant field
- Experience of administrative duties
- Experience within Primary Care.
Desirable
- Experience of working in Primary Care/Voluntary Sector/Community
-
- Experience in promoting health and health improvement within the community, including health
- Experience in Care Coordination
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.
