Job summary
We have a fantastic opportunity to join our innovative team of Care Co-ordinators working in the Stockport East and South (SES) Primary Care Network (PCN) in Stockport, specialising in Dementia and Frailty.
Two positions are available, and this role will involve working with patients with a range of presentations and their families and carers. The Care Co-ordinator will be integral in overseeing the interdisciplinary care and will be responsible for co-ordinating a package of care and support from a variety of specialists who may be working with the patient.
You will support all key activity across the PCN; supporting the PCN Manager and associated practices by co-ordinating activity and providing an efficient, well organised administrative and operational support to the clinicians and managers in the network to ensure effective timely delivery of the PCN objectives.
Main duties of the job
Care
Co-ordinator roles are new to Primary Care and we are looking to recruit an
Urgent Care, Frailty and Dementia Care Co-ordinator within the SES Primary Care
Network (PCN) across the borough. This role will involve working with patients
with a range of presentations and their families and carers. The care co-ordinator
will be integral in overseeing the interdisciplinary care and will be
responsible for co-ordinating a package of care and support from a variety of
specialists who may be working with the patient.
About us
Viaduct Care CIC is the company structure for Stockport's GP Federation and represents all of its local GP Practices. Covering a patient population of circa 300,000 practices are split into 6 PCNs with each serving a population of around 30,000-50,000 patients.
Viaduct Care represents the collective voice and interests of its member practices and as a key stakeholder in Stockport Together aims to influence and support the design and delivery of major service and system changes by being a strong and effective partner with other major service providers.
One of our priorities at Viaduct Care is to ensure that wellbeing and development of our team is at the forefront of everything we do. We have recently launched our new employee assistance programme, assisting our team to get access to a range of advice 24 hours a day. Additionally, we are keen to provide opportunities for team members to develop and grow including access to an extensive range of training and up to five paid study days per year.
Click on the Why Join Viaduct Care link to the right to find out about all of our staff support and benefits.
Job description
Job responsibilities
Main Roles & Responsibilities:
-
To
work as a team of Urgent Care, Frailty and Dementia Care Coordinators, with the
GPs and other primary care professionals within the PCN to proactively identify
and support some of our most vulnerable patients who require additional input
due to their presentation. The focus being those patients with moderate to
severe frailty, those with a diagnosis of dementia or cognitive impairment, and
those returning home after a recent admission to hospital, with the aim of
delivering proactive and reactive care to this group of patients.
-
Be
flexible to work collaboratively and support the other care coordinator teams
across the PCN with work that is required as directed by the PCN management
team.
- Be responsible for running weekly
EMIS searches to identify those moderately and severely frail patients, those
with recent admissions to hospital or ED attendances, particularly those
attending with falls and those with known dementia, contacting patients to
arrange appointments, whether in their own homes or bringing them into clinic.
- To visit these patients in their own
homes or see them within the practice where appropriate to complete a holistic
review of the patients health and social needs following an agreed assessment
pathway.
- Data collection and submission,
filing, general admin etc.
- Bring
together all a persons identified care and support needs and what matters to
them; explore the options to address these in a single personalised care and
support plan created in collaboration with the patient and their family as
appropriate.
- To support
with venepuncture and NHS Health Checks (pulse measurement, blood pressure
monitoring, height and weight measurement and waist measurement) where
required.
- Communicating
at least monthly with the PCN management team about ongoing workstreams and
work completed.
-
Raise awareness of shared decision-making and
decision support tools and assist people to be more prepared to have a shared
decision-making conversation.
-
Assist people to access self-management education
courses, peer support or interventions that support them in their health and
wellbeing; explore and assist people to access personal health budgets where
appropriate.
- Support the coordination and delivery
of multidisciplinary teams within PCN, in particular working with the PCN
Pharmacy team.
- Provide coordination and navigation for individuals
and their carers across health and care services, working closely with social
prescribing link workers and other primary care roles such as the Advanced
Community Practitioners/District nurses
- To help patients to manage their
needs through answering queries, making, and managing appointments
- Assist and coordinate practices in
meeting PCN DES, Locally Commissioned Service Targets and Impact and Investment
Fund (IIF) targets, and practice Quality Outcomes Framework (QoF) targets.
- Responsible for coordinating any
joint projects, e.g. vaccination and any associated administration
It should be
noted that whilst this job description lists the main areas of responsibility,
there may be additional tasks appropriately assigned by either the Clinical
Director or PCN Lead Manager to this role.
Job description
Job responsibilities
Main Roles & Responsibilities:
-
To
work as a team of Urgent Care, Frailty and Dementia Care Coordinators, with the
GPs and other primary care professionals within the PCN to proactively identify
and support some of our most vulnerable patients who require additional input
due to their presentation. The focus being those patients with moderate to
severe frailty, those with a diagnosis of dementia or cognitive impairment, and
those returning home after a recent admission to hospital, with the aim of
delivering proactive and reactive care to this group of patients.
-
Be
flexible to work collaboratively and support the other care coordinator teams
across the PCN with work that is required as directed by the PCN management
team.
- Be responsible for running weekly
EMIS searches to identify those moderately and severely frail patients, those
with recent admissions to hospital or ED attendances, particularly those
attending with falls and those with known dementia, contacting patients to
arrange appointments, whether in their own homes or bringing them into clinic.
- To visit these patients in their own
homes or see them within the practice where appropriate to complete a holistic
review of the patients health and social needs following an agreed assessment
pathway.
- Data collection and submission,
filing, general admin etc.
- Bring
together all a persons identified care and support needs and what matters to
them; explore the options to address these in a single personalised care and
support plan created in collaboration with the patient and their family as
appropriate.
- To support
with venepuncture and NHS Health Checks (pulse measurement, blood pressure
monitoring, height and weight measurement and waist measurement) where
required.
- Communicating
at least monthly with the PCN management team about ongoing workstreams and
work completed.
-
Raise awareness of shared decision-making and
decision support tools and assist people to be more prepared to have a shared
decision-making conversation.
-
Assist people to access self-management education
courses, peer support or interventions that support them in their health and
wellbeing; explore and assist people to access personal health budgets where
appropriate.
- Support the coordination and delivery
of multidisciplinary teams within PCN, in particular working with the PCN
Pharmacy team.
- Provide coordination and navigation for individuals
and their carers across health and care services, working closely with social
prescribing link workers and other primary care roles such as the Advanced
Community Practitioners/District nurses
- To help patients to manage their
needs through answering queries, making, and managing appointments
- Assist and coordinate practices in
meeting PCN DES, Locally Commissioned Service Targets and Impact and Investment
Fund (IIF) targets, and practice Quality Outcomes Framework (QoF) targets.
- Responsible for coordinating any
joint projects, e.g. vaccination and any associated administration
It should be
noted that whilst this job description lists the main areas of responsibility,
there may be additional tasks appropriately assigned by either the Clinical
Director or PCN Lead Manager to this role.
Person Specification
Qualifications
Essential
- Achieved grade C or above, in English and Maths GCSE or equivalent.
- Formal training in venepuncture (or be willing to work towards this).
- PCI Accredited Care Coordinator training (or be willing to work towards this).
Desirable
- NVQ Level III (Health and Social Care) or equivalent experience.
- Formal training in working with long term conditions.
Experience
Essential
- Committed to improving outcomes for older adults
- Experience of working autonomously and part of a team.
- Experience of working with older adults, including those with dementia, frailty or at risk of falls.
- Ability to recognise and respond appropriately to risk and safeguarding concerns
- Knowledge around importance of confidentiality and data protection
- Understanding of dementia, frailty syndromes and falls risk in older adults
Desirable
- Knowledge and understanding of Adult Social Care frameworks, policies, and local service provision
- Ability to undertake and interpret relevant clinical observations and tests (e.g., BP, MUST score, bloods) or willing to learn
- Experience in using care planning templates (e.g. Ardens) and digital systems
- Understanding of polypharmacy and medication reviews (liaising with SIPS/clinical pharmacist team)
- Evidence of working within a multidisciplinary team.
Skills and Other
Essential
- Good communication and interpersonal skills, including an ability to carry out DNAR and future planning discussions sensitively and appropriately
- Ability to carry out comprehensive assessments including: dementia reviews, frailty assessments and falls risk assessments
- Be able to offer support in a person centred and non-judgmental way
- Ability to plan and prioritise workload independently
- Ability to maintain accurate and concise records
- Ability to provide information effectively
- Good IT skills and proficient in the use of various Microsoft packages.
- Willingness to work and travel in settings across Stockport and ability to work from home if required.
- Have a full, clean driving license and have access to a car during all contractual hours.
- Commitment to working towards Viaduct Care CICs values and ethos as an organisation
- Ability to work flexibly in an innovative and developing role
Desirable
- Experience of working without direct supervision
Additional Attributes
Essential
- Willingness to work and travel in settings across Stockport and ability to work from home if required.
- Commitment to working towards Viaduct Care CIC's values and ethos as an organisation.
- Have a full, clean driving license and have access to a car during all contractual hours.
- Ability to work flexibly in an innovative and developing role.
Person Specification
Qualifications
Essential
- Achieved grade C or above, in English and Maths GCSE or equivalent.
- Formal training in venepuncture (or be willing to work towards this).
- PCI Accredited Care Coordinator training (or be willing to work towards this).
Desirable
- NVQ Level III (Health and Social Care) or equivalent experience.
- Formal training in working with long term conditions.
Experience
Essential
- Committed to improving outcomes for older adults
- Experience of working autonomously and part of a team.
- Experience of working with older adults, including those with dementia, frailty or at risk of falls.
- Ability to recognise and respond appropriately to risk and safeguarding concerns
- Knowledge around importance of confidentiality and data protection
- Understanding of dementia, frailty syndromes and falls risk in older adults
Desirable
- Knowledge and understanding of Adult Social Care frameworks, policies, and local service provision
- Ability to undertake and interpret relevant clinical observations and tests (e.g., BP, MUST score, bloods) or willing to learn
- Experience in using care planning templates (e.g. Ardens) and digital systems
- Understanding of polypharmacy and medication reviews (liaising with SIPS/clinical pharmacist team)
- Evidence of working within a multidisciplinary team.
Skills and Other
Essential
- Good communication and interpersonal skills, including an ability to carry out DNAR and future planning discussions sensitively and appropriately
- Ability to carry out comprehensive assessments including: dementia reviews, frailty assessments and falls risk assessments
- Be able to offer support in a person centred and non-judgmental way
- Ability to plan and prioritise workload independently
- Ability to maintain accurate and concise records
- Ability to provide information effectively
- Good IT skills and proficient in the use of various Microsoft packages.
- Willingness to work and travel in settings across Stockport and ability to work from home if required.
- Have a full, clean driving license and have access to a car during all contractual hours.
- Commitment to working towards Viaduct Care CICs values and ethos as an organisation
- Ability to work flexibly in an innovative and developing role
Desirable
- Experience of working without direct supervision
Additional Attributes
Essential
- Willingness to work and travel in settings across Stockport and ability to work from home if required.
- Commitment to working towards Viaduct Care CIC's values and ethos as an organisation.
- Have a full, clean driving license and have access to a car during all contractual hours.
- Ability to work flexibly in an innovative and developing role.
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.
