Care Coordinator, South & West Herefordshire PCN

Taurus Healthcare Limited

The closing date is 02 February 2022

Job summary

We are looking for a Care Coordinator to join the South & West Primary Care Network (PCN). This is an opportunity to support continuity of care for those who need it most. We are passionate about enabling personalised, joined up care and are looking for a new member of the S&W PCN Health & Wellbeing team to help us facilitate this for our patients in the S&W PCN

The successful candidate will work with each practice in the network. They will be a key player within a multi-disciplinary team, supporting care planning and coordinating communication between care homes, families, the general practice team, community, and mental health services.

This is an exciting opportunity to make a positive difference in how people and their families experience healthcare.

Main duties of the job

The Care Coordinator will coordinate care across the system, ensuring people access services which are joined up around their needs. The Care Coordinator will:

Co-ordinate care for patients as identified by the GP across health, social care, and mental health as appropriate, providing a single point of access for staff & service users into the Health & Wellbeing Team actively managing within the team appropriate allocation to services and the patients’ care plan delivery within a multi-disciplinary approach.

Facilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support.

Identify and work with a list of named patients with the aim of encouraging independence, reducing unnecessary admissions to hospitals, and supporting early discharge from hospital, improving the quality of care.

About us

The S&W PCN consists of 6 GP Practices working together and with our partner organisations to address health and wellbeing and health inequalities to a diverse and often rural population. We are very fortunate to be able to work closely together to understand the shared needs of our patient population and directly implement new ways of providing excellent patient care.

Taurus Healthcare was established in 2012, as the provider arm of the GP Federation serving 185,000 patients in Herefordshire. Founded and owned by the partners of the entire Herefordshire Primary Care community, Taurus is focused on providing excellent out of hospital services for patients. Our ethos is to provide high quality and cost-effective health outcomes that are delivered as close as possible to the patient’s home, whilst ensuring that patients who do require in hospital services are seen as quickly and effectively as possible.

Job description

Job responsibilities

JOB PURPOSE:

The Care Coordinator will have a key role in supporting delivery of the new Network Contract DES Service specifications.

Work within our network of GP Practices to provide a central co-ordination role for patient care planning. The role will involve working one to one with patients who need extra support, with the core responsibility being excellent patient care.

Co-ordinate care packages for patients as identified by the GP across health, social care and mental health as appropriate, providing a single-point of access for staff & service users, actively managing patients’ care plan delivery. This may include patients who are frail or vulnerable and who may live in residential / nursing settings.

Facilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support.

Identify and work with a list of named patients with the aim of encouraging independence, enabling people to remain at home, reducing unnecessary admissions to hospitals and supporting early discharge from hospital, improving the quality of care.

Work as essential team member within a multi-disciplinary team.

Provide feedback to the practices, troubleshoot and escalate actions as necessary, providing advocacy for service users.

MAIN RESPONSIBILITIES

1. Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames.

2. Explain the management of a patient’s pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms.

3. Work closely with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated delivery of the patient’s care plan, without requiring a further referral from the GP.

4. Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame.

5. Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations’ communications & patient notes and ensuring care packages are set up.

6. Collect data on patients/carers for recognised outcome measure and document for service interpretation. Ensure all patient notes are updated to reflect any changes, including details on plans

7. Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and lead the meetings. Organise and attend relevant meetings when required including multi-disciplinary team meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance.

8. Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.

9. Network and develop strong relationships with all levels of the NHS’s key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector.

10. Be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders.

Person Specification

Experience

Essential

  • Working knowledge of Microsoft office Word, Excel, Outlook and PowerPoint and using video calling software e.g. Microsoft teams.
  • Experience of using IT systems such as EMIS.
  • Experience of working in a health or social care setting.
  • Experience of partnership/collaborative working and of building relationships across a variety of organisations.
  • Knowledge of the personalised care approach.
  • Experience of providing one to one and/or group support.

Desirable

  • Experience of using the Patient Activation Measure (PAM) to assess knowledge, skills and confidence.

Qualifications

Essential

  • GCSE English or equivalent level.
  • GCSE Mathematics or equivalent level.

Desirable

  • ECDL or equivalent level of keyboard/IT skills.

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.

Employer details

Employer name

Taurus Healthcare Limited

Address

Suite 1, Berrows Business Centre

Bath Street

Hereford

Herefordshire

HR1 2HE


Employer's website

https://www.herefordshiregeneralpractice.co.uk (Opens in a new tab)

For help with your application, contact:

Date posted

13 January 2022

Pay scheme

Other

Salary

£22,000 to £23,000 a year

Contract

Permanent

Working pattern

Full-time

Reference number

S0001-22-1822

Job locations

Suite 1, Berrows Business Centre

Bath Street

Hereford

Herefordshire

HR1 2HE


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