Job summary
You will work with GP practice teams to coordinate the care of patients with frailty, cancer, long term conditions, safeguarding and social issues, patients requiring proactive care, and patients who require support to communicate effectively. You will liaise with the patient, practice team, secondary care teams, social services, the voluntary and community sector, and other members of the Primary Care Network team to help smooth the patients pathway, expedite care where appropriate, and follow up letters and results.
You will support the practice to deliver good quality care for frail patients, patients in palliative care, and patients with long term conditions. You will work with the practice team to prepare for effective GSF and frailty meetings, and ensure that processes such as falls assessments and medication reviews are carried out in a timely manner. Where appropriate, you will help develop a personalised care and support plan for these patients. You will support the practice to ensure that patients are reviewed at an appropriate frequency, and to achieve QOF, IIF, and LIAISE targets.
You will be working as part of the Teesdale PCN team to support the patients of Old Forge Surgery. This is a part time position for 18.75 hours.
Main duties of the job
Work with practices to coordinate care for patients with greater needs, to improve the patient pathway & expedite care as appropriate. Support the delivery of the practice GSF & frailty programmes Support the achievement of practice quality standards including QOF, IIF, & LIAISE
Work closely & in partnership with the Social Prescribing Link Workers,to address wider determinants of health, such as poor housing, debt, stress and loneliness and identify and prioritise a person's care/support needs in a single personalised care and support plan, based on what matters to the person in shared decision making process.
Help patients manage their needs through answering queries, making & managing appointments, & ensuring that people have access to good quality information about their care
Coordinate appointments & encourage uptake of vaccinations in eligible populations
Encouraging uptake of QOF LTC Annual & Structured Medication Reviews
Encouraging the delivery of good quality annual health checks for patients with learning disabilities & SMI
Supporting cancer screening, including FIT tests/bowel screening, cervical screening, and breast screening. Refer smokers to smoking cessation. Safetynetting two week wai
About us
A group of 12 GP practices across Durham Dales got together, looking for a solution to help them provide the care patients needed, share resources and ideas, and be prepared for the challenges the NHS would face in the future.The answer they came up with was a formal collaboration between the dozen practices: the Durham Dales Health Federation. DDHFs founding principal is to work together to provide high-quality, cost effective primary healthcare services.That means providing a range of services that all GP practices in the area can use to help look after patients.We employ a range of clinical staff pharmacists, dispensers, nurses, emergency care practitioners and social prescribing link workers as well as non-clinical, administration support staff.
Benefits DDHF can offer; paid mileage. NHS pension. A car lease scheme which is transferable. We fully support training & development. Regular 1-2-1 support & appraisal. Cycle to work Scheme (salary sacrifice bike).Dress Down Friday(office workers). Complimentary refreshments. Free Car Park, Health service discounts, Immunisations offered, Eye tests reimbursed.
Job description
Job responsibilities
Work with practice teams to
coordinate care for patients with greater needs, to improve the patient pathway
and expedite care as appropriate
Proactively identify patients
who require care coordination, using agreed criteria and population health
tools as appropriate
Support the delivery of the
practice GSF and frailty programmes
Support the achievement of
practice quality standards including QOF, IIF, and LIAISE
Work closely and in partnership
with the Teesdale Social Prescribing Link Workers, to assist patients to take
up training and employment and access benefits
Help patients manage their
needs through answering queries, making and managing appointments, and ensuring
that people have access to good quality information about their care
Assist people to access
personal health budgets where appropriate
Coordinate appointments and
encourage uptake of vaccinations in eligible populations
Utilise and demonstrate sensitive communication
styles, to ensure patients are fully informed and consent to treatment
Support patients to use decision aids in preparation for shared
decision making conversations
Communicate effectively with patients and
carers, recognising the need for alternative methods of communication to
overcome different levels of understanding, cultural background and preferred
ways of communicating
Anticipate
barriers to communication and take action to improve communication
Maintain effective communication within the PCN and with external stakeholders
Job description
Job responsibilities
Work with practice teams to
coordinate care for patients with greater needs, to improve the patient pathway
and expedite care as appropriate
Proactively identify patients
who require care coordination, using agreed criteria and population health
tools as appropriate
Support the delivery of the
practice GSF and frailty programmes
Support the achievement of
practice quality standards including QOF, IIF, and LIAISE
Work closely and in partnership
with the Teesdale Social Prescribing Link Workers, to assist patients to take
up training and employment and access benefits
Help patients manage their
needs through answering queries, making and managing appointments, and ensuring
that people have access to good quality information about their care
Assist people to access
personal health budgets where appropriate
Coordinate appointments and
encourage uptake of vaccinations in eligible populations
Utilise and demonstrate sensitive communication
styles, to ensure patients are fully informed and consent to treatment
Support patients to use decision aids in preparation for shared
decision making conversations
Communicate effectively with patients and
carers, recognising the need for alternative methods of communication to
overcome different levels of understanding, cultural background and preferred
ways of communicating
Anticipate
barriers to communication and take action to improve communication
Maintain effective communication within the PCN and with external stakeholders
Person Specification
Qualifications
Essential
- GCSE Grade A-C in Maths &
- English or skills level 2
- Maths & English or
- equivalent
Desirable
- Qualification in a health or social care allied profession
Experience
Essential
- Experience of providing andreceiving complex, sensitiveinformation
Desirable
- Experience working in a primary care setting
Knowledge & Skills
Essential
- Demonstrate an appreciation of the health needs of patients in the Teesdale area
- Communication skills, both written and verbal
- Empathy with the patients needs and conditions
- Positive attitude to work, colleagues and patients
- Non-judgemental attitude to patients
- Tact and diplomacy
- Desire to help and put people first
- Ability to negotiate the best possible services for patients
- Advocacy skills
- Time management
- Team working
- Good IT keyboard skills
Desirable
- Knowledge of community based primary care issues
- Knowledge of primary care networks and collaborative ways of working
- Understanding of safeguarding principles.
- Knowledge of SystmOne information system
Other
Essential
- Full UK driving Licence
- Willingness to travel between GP practices and work from various locations in the Dales area
- Highly motivated
- Enthusiastic and confident
Person Specification
Qualifications
Essential
- GCSE Grade A-C in Maths &
- English or skills level 2
- Maths & English or
- equivalent
Desirable
- Qualification in a health or social care allied profession
Experience
Essential
- Experience of providing andreceiving complex, sensitiveinformation
Desirable
- Experience working in a primary care setting
Knowledge & Skills
Essential
- Demonstrate an appreciation of the health needs of patients in the Teesdale area
- Communication skills, both written and verbal
- Empathy with the patients needs and conditions
- Positive attitude to work, colleagues and patients
- Non-judgemental attitude to patients
- Tact and diplomacy
- Desire to help and put people first
- Ability to negotiate the best possible services for patients
- Advocacy skills
- Time management
- Team working
- Good IT keyboard skills
Desirable
- Knowledge of community based primary care issues
- Knowledge of primary care networks and collaborative ways of working
- Understanding of safeguarding principles.
- Knowledge of SystmOne information system
Other
Essential
- Full UK driving Licence
- Willingness to travel between GP practices and work from various locations in the Dales area
- Highly motivated
- Enthusiastic and confident
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
Durham Dales Health Federation
Address
Unit 51 Innovation Hse, Longfield Rd
South Church Enterprise Park
Bishop Auckland
Durham
DL14 6XB
Employer's website
https://ddhf.co.uk/ (Opens in a new tab)
