Job summary
This is an exciting opportunity for the right candidate(s) to work within the 5 practices that form part of PCN Wakefield Health Alliance South, creating and implementing this new role, supporting patients, by coordinating their health and social care needs, specifically house bound patients andresidents of nursing and care homes.
Our PCN has already employed new team members, including; pharmacists, social prescribers, physiotherapists, paramedics health and wellbeing coaches and a mental health practitioner, and are now in a position to recruit Care Co-ordinators to join us to be part of a great team.
The successful candidate will play a key role in proactively identifying and working with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
The Care Co-ordinator will be involved in supporting the clinical team to proactively identify and work with patients, to provide proactive, person centered care planning, by bringing together the different specialist services an individual might need to improve their quality of life.
The Care co-cordinator will be a key contact, helping patients navigate social and health care, while supporting them to understand and manage their conditions, ensuring changing needs are met with a hope to reduce unplanned hospital admission's.
Networking and training opportunities will be provided to support the development of this role.
Main duties of the job
This is new and developing role within our PCN, and the successful candidate will have excellent interpersonal and communication skills, and be organised, patient and empathetic. They will have experience of working in health, social care or other support roles including direct contact with people, families or carers.
The main duties/responsibilities of the role is to proactively:
Identify patients who are
deemed at high risk of hospital admission
Reduce unplanned hospital
admissions
Reduce the length of stay
in hospital where admission is necessary
Engage with patients
living in care homes, to ensure personalised care and support plans are completed in line with PCN targets.
Liaising with Care Home Managers to discuss and plan residents needs while building good working relationships and forming MDT's
To maintain and develop engagement with GP's, practice staff and community staff.
Support housebound
patients
Support patients with long-term conditions,
working alongside primary care colleagues
You will need to display a compassionate nature, be knowledgeable about health care practices, and provide exceptional customer service. The role would be ideal for someone with proven experience as primary care healthcare assistant or other clinical
About us
Wakefield Health Alliance South consists of 5 member GP practices on the eastern side of the Wakefield District, covering a total population of approximately 68,000 people. Together we work in partnership towards improving the health and wellbeing of our residents.
PCN South practices are based in Hemsworth, Havercroft, South Kirkby, South Elmsall and Ackworth serving patients in each of these areas.
We are a friendly and forward thinking PCN, and support development and progression of our team memebers.
Job applicants should be aware of the guidance from NHS England and NHS Improvement, that a formal announcement has been made that individuals undertaking CQC regulated activities in England must be fully vaccinated against Covid 19 by no later than 1 April 2022 to protect patients. These regulations are expected to come into force from 1 April 2022 and therefore, those who are unvaccinated are encouraged to ensure that they have had their first does of the vaccination by 3 February 2022 in order to ensure they have received their second does by 1 April 2022. There are specific exemptions includes those who are medically exempt. Potential job applicants are therefore, asked to consider the above information when applying for a role with this organisation as some/all of our activities are covered by the proposals.
Job description
Job responsibilities
Job Summary
Care Co-ordinators provide extra time and
expertise to support patients in preparing for, or in following-up, clinical
conversations they have with primary care professionals. They will work closely
with the GPs and other primary care professionals within the PCN to identify
and manage a caseload of identified patients, making sure that appropriate
support is made available to them and their carers; ensuring their changing
needs are addressed.
The post holder will be responsible for
consulting with patients, including care home residents and those that are
housebound to determine their needs, developing care plans, co-ordinating
patient care services, educating them about their condition, and working with
the care team to evaluate interventions.
You will need to display a compassionate nature
and be knowledgeable about health care practices.
Main Duties and Responsibilities
Proactively identify
and work with a cohort of patients to support their personalised care
requirements
Consult with patients and family members to bring together all of their
identified care needs into a single personalised care and support plan
Educate patients about their condition, medication, and provide
specific instructions on how to manage their needs, answering queries and supporting
them to make appointments
Ensure that people have
good quality information to help them make choices about their care
Assist patients to
access self-management education courses, peer support or interventions that
support them in their health and wellbeing
Ensure that patients
have good quality information to help them make choices about their care
Navigate and signpost patients and their
carers appropriately, working alongside health and wellbeing coaches, social
prescribing link workers and other primary care roles
Carry out home visits as necessary
Develop and maintain effective and productive relationships with
practice staff and other teams, referring and liaising with them in the best
interest of the patients care
Support patients to
take up training and employment and assist with benefit
claims working collaboratively with DWP Work Coaches
Check-in on the patients regularly and evaluate and document their
progress
Monitor DNAs for specific cohorts of patients
Attend and support the
co-ordination and delivery of MDT meetings, to include the recording, minuting
and monitoring outcomes and actions from these meetings as required.
The Care Co-ordinators
role is critical in ensuring that patients are signposted to the correct health,
social or voluntary agency in a timely manner
To provide a single
point of contact for primary care staff and the PCN to support them with
investigating patient case history to improve co-ordination of care
Job description
Job responsibilities
Job Summary
Care Co-ordinators provide extra time and
expertise to support patients in preparing for, or in following-up, clinical
conversations they have with primary care professionals. They will work closely
with the GPs and other primary care professionals within the PCN to identify
and manage a caseload of identified patients, making sure that appropriate
support is made available to them and their carers; ensuring their changing
needs are addressed.
The post holder will be responsible for
consulting with patients, including care home residents and those that are
housebound to determine their needs, developing care plans, co-ordinating
patient care services, educating them about their condition, and working with
the care team to evaluate interventions.
You will need to display a compassionate nature
and be knowledgeable about health care practices.
Main Duties and Responsibilities
Proactively identify
and work with a cohort of patients to support their personalised care
requirements
Consult with patients and family members to bring together all of their
identified care needs into a single personalised care and support plan
Educate patients about their condition, medication, and provide
specific instructions on how to manage their needs, answering queries and supporting
them to make appointments
Ensure that people have
good quality information to help them make choices about their care
Assist patients to
access self-management education courses, peer support or interventions that
support them in their health and wellbeing
Ensure that patients
have good quality information to help them make choices about their care
Navigate and signpost patients and their
carers appropriately, working alongside health and wellbeing coaches, social
prescribing link workers and other primary care roles
Carry out home visits as necessary
Develop and maintain effective and productive relationships with
practice staff and other teams, referring and liaising with them in the best
interest of the patients care
Support patients to
take up training and employment and assist with benefit
claims working collaboratively with DWP Work Coaches
Check-in on the patients regularly and evaluate and document their
progress
Monitor DNAs for specific cohorts of patients
Attend and support the
co-ordination and delivery of MDT meetings, to include the recording, minuting
and monitoring outcomes and actions from these meetings as required.
The Care Co-ordinators
role is critical in ensuring that patients are signposted to the correct health,
social or voluntary agency in a timely manner
To provide a single
point of contact for primary care staff and the PCN to support them with
investigating patient case history to improve co-ordination of care
Person Specification
Qualifications
Essential
- GCSE grade C (4) or above in English and Maths, or equivalent
Experience
Essential
- * Experience of working in health, social care and other support roles in
- direct contact with people, families or carers.
- * Experience of working in a multi-professional team environment
- * Confident in using Email and sound IT knowledge
- * Be adaptable and self motivated using initiative and clinical judgements
- * Enthusiasm and commitment to achieving better outcomes for patients
Desirable
- * Higher level qualification such as NVQ in adult care level 3
- * Previous use of SystemOne
- * Experience or knowledge in chronic disease management eg Diabetes,
- asthma, COPD etc.
- * Knowledge of how the wider NHS works, including PCN's
Person Specification
Qualifications
Essential
- GCSE grade C (4) or above in English and Maths, or equivalent
Experience
Essential
- * Experience of working in health, social care and other support roles in
- direct contact with people, families or carers.
- * Experience of working in a multi-professional team environment
- * Confident in using Email and sound IT knowledge
- * Be adaptable and self motivated using initiative and clinical judgements
- * Enthusiasm and commitment to achieving better outcomes for patients
Desirable
- * Higher level qualification such as NVQ in adult care level 3
- * Previous use of SystemOne
- * Experience or knowledge in chronic disease management eg Diabetes,
- asthma, COPD etc.
- * Knowledge of how the wider NHS works, including PCN's
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.
