Care Co-ordinator

Taurus Healthcare Limited

Information:

This job is now closed

Job summary

The N&W PCN are recruiting to a Care Coordinator post who will work with practices across the N&W Primary Care Network (PCN) managing their MDT meetings, supporting discharges across care settings as well as admissions and ward rounds for care homes. The care coordinator will work closely with the N&W PCNs Wellbeing Team Care Coordinator to support patients holistically.

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.

Main duties of the job

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.

About us

The North & West Herefordshire PCN GP practices serve rural and market town communities responding to the wide - ranging health needs of the population. The network includes Kington Medical Practice, The Marches Surgery Leominster, The Mortimer Medical Practice Kingsland, Tenbury Wells Surgery, Weobley and Staunton on Wye surgeries and Westfield Surgery Leominster. It is a highly organised and forward looking PCN with strong relationships between practices and community providers.

Come and work with us and be part of this exciting new development, working in partnership with patients and enabling excellent care.

Date posted

18 January 2022

Pay scheme

Other

Salary

£23,000 a year

Contract

Permanent

Working pattern

Full-time

Reference number

S0001-22-8398

Job locations

Suite 1, Berrows Business Centre

Bath Street

Hereford

Herefordshire

HR1 2HE


Job description

Job responsibilities

JOB PURPOSE:

The Care Coordinator will work with practices across the N&W Primary Care Network (PCN) managing their MDT meetings, supporting discharges across care settings as well as admissions and ward rounds for care homes. The care coordinator will work closely with the N&W PCNs Wellbeing Team Care Coordinator to support patients holistically.

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.

Job description

Job responsibilities

JOB PURPOSE:

The Care Coordinator will work with practices across the N&W Primary Care Network (PCN) managing their MDT meetings, supporting discharges across care settings as well as admissions and ward rounds for care homes. The care coordinator will work closely with the N&W PCNs Wellbeing Team Care Coordinator to support patients holistically.

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

Qualifications

Essential

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

Desirable

  • ECDL or equivalent level of keyboard/IT skills.

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.
Person Specification

Qualifications

Essential

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

Desirable

  • ECDL or equivalent level of keyboard/IT skills.

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.

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)

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 questions about the job, contact:

Date posted

18 January 2022

Pay scheme

Other

Salary

£23,000 a year

Contract

Permanent

Working pattern

Full-time

Reference number

S0001-22-8398

Job locations

Suite 1, Berrows Business Centre

Bath Street

Hereford

Herefordshire

HR1 2HE


Supporting documents

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