Job summary
We have a fantastic opportunity to join our innovative team of Care Co-ordinators working across the Stockport borough, specialising in care of vulnerable patient groups.
This role will involve working with individuals with learning disabilities, those requiring safeguarding oversight, and patients living with cancer.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 a Vulnerable Patients Care Co-ordinator to work across the Stockport borough. This role aims to improve health outcomes, promote timely care, and reduce health inequalities through effective care planning, system navigation, and communication between patients, carers, and the healthcare team.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 Role and Responsibilities
To work as a team of Vulnerable Patient 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 learning
disabilities, those on the safeguarding register, those with diagnosis of
cancer and to support with cancer screening uptake as well.
- 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.
- In some cases, especially when working with patients with learning
disabilities, 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.
- 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 roles such as social services, school nurses, health visitors
and midwives.
- 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.
- Promote vaccination, screening and health improvement across patient
groups
- Work closely with GPs, nurses, social prescribers and external agencies
to ensure coordinated care.
The role includes working together as a
team of care coordinators to support the below groups of patients. Some aspects
of the role are indicated under each heading.
1. Learning
Disabilities (LD)
- Maintain
and update LD registers, ensuring accurate coding and data.
- Coordinate
and promote annual LD health checks.
- Liaise
with GPs and nurses to allocate patients and schedule appointments in the
correct order (care coordinator nurse GP).
- Complete
pre-health check reviews using the Ardens LD template
- Promote
vaccinations (MMR, flu, COVID) and cancer screening.
- Liaise
with community and childrens LD teams when appropriate.
- Act
as a point of contact for LD patients and carers for navigation and support.
2.
Safeguarding
- Maintain and
update adult and child safeguarding lists for aligned practices.
- Organise and
minute bi-monthly safeguarding meetings, documenting outcomes in EMIS.
- Complete Child Protection
Case Conference reports using EMIS templates and submit via the agreed process.
- Contact and
support families of children awaiting CAMHS, offering signposting and welfare
checks.
- Monitor and
respond to DNAs for vulnerable children and adults, using appropriate templates
and flagging concerns.
- Liaise with
safeguarding leads and attend multi-agency meetings as appropriate.
- Support the
welfare of parents' mental health when capacity allows, using structured
check-ins and signposting.
3. Cancer
Care Coordination
- Conduct and
document 3-month and 12-month cancer care reviews.
- Maintain the
Gold Standards Framework (GSF) register and ensure care plans/DNACPR status are
documented and uploaded to EPAACs.
- Organise and
minute monthly GSF meetings with practices, involving DNs/Macmillan as
required.
- Promote cancer
awareness campaigns and screening programmes (smear, bowel, breast) across
practices and actively follow up patients who have refused or not responded to
screening invitations.
- Support PCN
audit work on cancer diagnoses to identify improvement opportunities for early
diagnosis.
- Monitor DNAs
for cancer and frail patients, identifying barriers and supporting
re-engagement.
4. ED
attendances and DNAs
- Monitor DNAs
for vulnerable patients, contacting patients/carers, identifying barriers, and
supporting re-engagement.
- Monitor A and E
attendances in under 18s, contacting families when appropriate to discuss
alternatives to ED, health needs, and safeguarding concerns.
- Use Ardens
templates consistently to document contacts and interventions.
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 to meet the needs of our patients in
an ever changing healthcare environment.
Job description
Job responsibilities
Main Role and Responsibilities
To work as a team of Vulnerable Patient 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 learning
disabilities, those on the safeguarding register, those with diagnosis of
cancer and to support with cancer screening uptake as well.
- 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.
- In some cases, especially when working with patients with learning
disabilities, 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.
- 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 roles such as social services, school nurses, health visitors
and midwives.
- 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.
- Promote vaccination, screening and health improvement across patient
groups
- Work closely with GPs, nurses, social prescribers and external agencies
to ensure coordinated care.
The role includes working together as a
team of care coordinators to support the below groups of patients. Some aspects
of the role are indicated under each heading.
1. Learning
Disabilities (LD)
- Maintain
and update LD registers, ensuring accurate coding and data.
- Coordinate
and promote annual LD health checks.
- Liaise
with GPs and nurses to allocate patients and schedule appointments in the
correct order (care coordinator nurse GP).
- Complete
pre-health check reviews using the Ardens LD template
- Promote
vaccinations (MMR, flu, COVID) and cancer screening.
- Liaise
with community and childrens LD teams when appropriate.
- Act
as a point of contact for LD patients and carers for navigation and support.
2.
Safeguarding
- Maintain and
update adult and child safeguarding lists for aligned practices.
- Organise and
minute bi-monthly safeguarding meetings, documenting outcomes in EMIS.
- Complete Child Protection
Case Conference reports using EMIS templates and submit via the agreed process.
- Contact and
support families of children awaiting CAMHS, offering signposting and welfare
checks.
- Monitor and
respond to DNAs for vulnerable children and adults, using appropriate templates
and flagging concerns.
- Liaise with
safeguarding leads and attend multi-agency meetings as appropriate.
- Support the
welfare of parents' mental health when capacity allows, using structured
check-ins and signposting.
3. Cancer
Care Coordination
- Conduct and
document 3-month and 12-month cancer care reviews.
- Maintain the
Gold Standards Framework (GSF) register and ensure care plans/DNACPR status are
documented and uploaded to EPAACs.
- Organise and
minute monthly GSF meetings with practices, involving DNs/Macmillan as
required.
- Promote cancer
awareness campaigns and screening programmes (smear, bowel, breast) across
practices and actively follow up patients who have refused or not responded to
screening invitations.
- Support PCN
audit work on cancer diagnoses to identify improvement opportunities for early
diagnosis.
- Monitor DNAs
for cancer and frail patients, identifying barriers and supporting
re-engagement.
4. ED
attendances and DNAs
- Monitor DNAs
for vulnerable patients, contacting patients/carers, identifying barriers, and
supporting re-engagement.
- Monitor A and E
attendances in under 18s, contacting families when appropriate to discuss
alternatives to ED, health needs, and safeguarding concerns.
- Use Ardens
templates consistently to document contacts and interventions.
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 to meet the needs of our patients in
an ever changing healthcare environment.
Person Specification
Experience
Essential
- Previous experience working in healthcare, care or community setting
- Experience of working autonomously and part of a team
- Ability to recognise and respond appropriately to risk and safeguarding concerns
- Knowledge around importance of confidentiality and data protection
Desirable
- Experience of working in Primary Care
- Experience of working with Cancer/Learning Disabilities/Safeguarding
- Experience using clinical systems and MS office for record driving
- Evidence of working within a multidisciplinary team
- Previous experience of care coordination, learning disabilities, safeguarding or cancer care
Skills and Other
Essential
- Good communication and interpersonal skills, including an ability to build rapport and establish good one to one relationships
- Ability to deal with challenging behaviour and difficult conversations
- Be able to offer support in a person centred and non-judgmental way
- Ability to effectively manage a variable workload
- 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 in settings across Stockport
- Commitment to working towards Viaduct Care CICs values and ethos as an organisation
- Commitment to reducing health inequalities and improving outcomes for vulnerable groups
- Must drive and have access to a vehicle for work-related travel across sites and for potential home visits
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.
Qualifications
Essential
- Achieved grade C or above, in English and Maths GCSE or equivalent
- NVQ Level III (Health and Social Care) or equivalent or equivalent experience
Desirable
- Formal training in working with long term conditions.
Person Specification
Experience
Essential
- Previous experience working in healthcare, care or community setting
- Experience of working autonomously and part of a team
- Ability to recognise and respond appropriately to risk and safeguarding concerns
- Knowledge around importance of confidentiality and data protection
Desirable
- Experience of working in Primary Care
- Experience of working with Cancer/Learning Disabilities/Safeguarding
- Experience using clinical systems and MS office for record driving
- Evidence of working within a multidisciplinary team
- Previous experience of care coordination, learning disabilities, safeguarding or cancer care
Skills and Other
Essential
- Good communication and interpersonal skills, including an ability to build rapport and establish good one to one relationships
- Ability to deal with challenging behaviour and difficult conversations
- Be able to offer support in a person centred and non-judgmental way
- Ability to effectively manage a variable workload
- 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 in settings across Stockport
- Commitment to working towards Viaduct Care CICs values and ethos as an organisation
- Commitment to reducing health inequalities and improving outcomes for vulnerable groups
- Must drive and have access to a vehicle for work-related travel across sites and for potential home visits
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.
Qualifications
Essential
- Achieved grade C or above, in English and Maths GCSE or equivalent
- NVQ Level III (Health and Social Care) or equivalent or equivalent experience
Desirable
- Formal training in working with long term conditions.
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.
