Job summary
Cross Gates Primary Care Network includes
four practices working across seven sites: Ashfield and The Grange Medical
Centre, Colton Mill and The Grange Medical Centre, Family Doctors and Manston
and Surgery. The PCN has a patient population of 30,000 including patients
living across 5 care homes.
We believe in providing a holistic approach
to managing patient care and supporting individuals to meet their own needs and
aspirations. You will be part of an organisation whose leadership team are
supportive and innovative, focused on change and transforming services.
Our team currently
includes pharmacists, pharmacy
technician, mental health practitioners, advanced clinical practitioner,
admiral nurse, nurse associate, physician associate, first contact
physiotherapists, health and wellbeing coaches and care coordinators, with the aim
of supporting our practices and improving health outcomes for our patients. We
do this through the integration of PCN teams and services with our practices, continuous
evaluation, and ongoing development of our services and projects, looking for
opportunities for innovation and transformation and sharing best practice.
To address the healthcare needs of our local population we are hoping to
employ a care coordinator to
join our PCN team, which currently includes.
Main duties of the job
Our Care Coordinators play an important role
within the PCN to reduce health inequalities and support meeting our PCN and
practice targets. They work closely with practice and PCN staff to identify,
engage with and coordinate personalised care and support planning for the most
vulnerable people in our community, including the frail/elderly, patients with
dementia and their carers, patients diagnosed with cancer, care home residents
and those with long-term health conditions.
As well as being linked with individual
practices they will work together as a team. This includes sharing learning and
best practice both within the team and across the PCN.
Our Care Coordinators support Clinical Leads
and the Multi-Disciplinary team in the organisation and facilitation of MDT
meetings including weekly Care homes meetings.
About us
They run reports to proactively identify
eligible patients and work to increase uptake of health checks, cancer
screening, vaccinations and other services including self-management services.
Support with patient engagement, which includes ensuring that information is
accessible for all and having conversations with patients and carers to
increase understanding, alleviate concerns and increase engagement and
self-management.
They support people in preparing for or
following-up clinical conversations with primary care professionals (including
health checks) to enable them to be actively involved in managing their care
and supported to make choices that are right for them. You will use knowledge
of health and social services available in the locality, including those
offered by the community and voluntary sector, to link people up with these and
help them overcome any barriers they might encounter. The aim is to help people
improve their quality of life and avoid unplanned hospital admissions.
Care Coordinators act as a central point of
contact to ensure that patients receive the best possible care, and the person
is supported to achieve the outcomes that are important to them. This is
achieved by bringing together all the information about a persons identified
care and support needs and exploring options to meet these within a single
personalised care and support plan, based on what matters to the person.
Job description
Job responsibilities
Coordinate
multidisciplinary meetings across local care organisations including
identifying patients in need of review and collating any information required
to facilitate their review prior to the meeting.
Provide admin support
to multidisciplinary meetings including taking minutes.
Utilise GP Practice
clinical systems SystmOne and EMIS and population health data to proactively
identify relevant cohorts of patients to deliver personalised care
Support patients within
these cohorts to access health checks and other health services
Support the PCN in
improving overall patient care through promotion of services available to them
locally within the PCN and the wider health system
Liaise with other key
stakeholders as needed for the collective benefit of the patient including but
not limited to GPs, nurses, pharmacists and other support staff from within the
PCN practices or from other provider organisations
Communicate effectively
and sensitively using language appropriate to the patient and their carer and
their level of understanding
Raise awareness of
shared decision making and decision support tools, and assist patients to be
more prepared for shared decision making conversations
To provide coordination
and navigation for patients and their carers across health and social care
services, where appropriate linking with social prescribers and other patient
link workers in the PCN
Work in partnership
with key providers in the local community to enable improved access to services
for patients
Work with practices to
support delivery of any national and local targets outlined in the GP contract
Contacting patients to
increase uptake in designated clinics such as vaccinations, cancer screening
and health reviews. Identifying reasonable adjustments that can be made for
vulnerable groups of patients, to provide a more suitable environment to
deliver their care.
Coordinating case load
visits for reviews or vaccinations to support the clinical team.
Undertake quality
improvement audits to identify best practice or areas to improve and share
learning across the PCN.
Participate in PCN
workshops/training sessions relevant to the Care Coordinator role.
Job description
Job responsibilities
Coordinate
multidisciplinary meetings across local care organisations including
identifying patients in need of review and collating any information required
to facilitate their review prior to the meeting.
Provide admin support
to multidisciplinary meetings including taking minutes.
Utilise GP Practice
clinical systems SystmOne and EMIS and population health data to proactively
identify relevant cohorts of patients to deliver personalised care
Support patients within
these cohorts to access health checks and other health services
Support the PCN in
improving overall patient care through promotion of services available to them
locally within the PCN and the wider health system
Liaise with other key
stakeholders as needed for the collective benefit of the patient including but
not limited to GPs, nurses, pharmacists and other support staff from within the
PCN practices or from other provider organisations
Communicate effectively
and sensitively using language appropriate to the patient and their carer and
their level of understanding
Raise awareness of
shared decision making and decision support tools, and assist patients to be
more prepared for shared decision making conversations
To provide coordination
and navigation for patients and their carers across health and social care
services, where appropriate linking with social prescribers and other patient
link workers in the PCN
Work in partnership
with key providers in the local community to enable improved access to services
for patients
Work with practices to
support delivery of any national and local targets outlined in the GP contract
Contacting patients to
increase uptake in designated clinics such as vaccinations, cancer screening
and health reviews. Identifying reasonable adjustments that can be made for
vulnerable groups of patients, to provide a more suitable environment to
deliver their care.
Coordinating case load
visits for reviews or vaccinations to support the clinical team.
Undertake quality
improvement audits to identify best practice or areas to improve and share
learning across the PCN.
Participate in PCN
workshops/training sessions relevant to the Care Coordinator role.
Person Specification
Personal Qualities
Essential
- Flexibility and adaptability to develop the role within PCN business needs.
- Demonstrate the ability to value others
- Punctual and reliable
- Highly motivated and enthusiastic
- High levels of integrity and loyalty
- Team player
- Ability to work under pressure and timescales
- Ability to work in an environment of change to meet the needs of primary care
Experience
Desirable
- Experience of working in a primary care setting
- Use of clinical systems
- Experience of working with people who may face health inequalities e.g. living with frailty, people with living with learning disabilities or severe mental illness, and/or carers
- Experience of working in health, social care or other support roles which are in direct contact with people, families or carers
Knowledge and Skills
Essential
- Administrative duties including preparing for meetings and writing minutes
- Has attention to details, able to work accurately, identifying errors quickly and easily
- Has a planned and organised approach with an ability to priority their own workload to meet strict deadlines
- Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience
- An excellent understanding of data protection and confidentiality issues
- Self-motivated, pro-active and able to work independently
- Continued commitment to improve skills and abilities in new areas of work
- Able to undertake the demands of the post with reasonable adjustment if required
- Able to access transport to work across the practices within the PCN and attend meetings in other locations
- Excellent time keeping and prioritisation skills
- Professional attributes and appearance
- Excellent IT skills and the ability to run reports and interpret and analyse and present data
Desirable
- Understanding of medical technology around frailty, population health management and long term conditions
Other requirements
Essential
- Flexibility to work outside of core office hours including extended hours services
- Disclosure Barring Service DBS check
- Hold a Valid UK Driving License and have access to own transport with business insurance and ability to travel across the locality on a regular basis, including visiting people in their own home or care home.
Qualifications
Essential
- GCSE grade A-C in Maths and English or skills level 2 in Maths and English or equivalent
Desirable
- ECDL or other equivalent IT qualification
Person Specification
Personal Qualities
Essential
- Flexibility and adaptability to develop the role within PCN business needs.
- Demonstrate the ability to value others
- Punctual and reliable
- Highly motivated and enthusiastic
- High levels of integrity and loyalty
- Team player
- Ability to work under pressure and timescales
- Ability to work in an environment of change to meet the needs of primary care
Experience
Desirable
- Experience of working in a primary care setting
- Use of clinical systems
- Experience of working with people who may face health inequalities e.g. living with frailty, people with living with learning disabilities or severe mental illness, and/or carers
- Experience of working in health, social care or other support roles which are in direct contact with people, families or carers
Knowledge and Skills
Essential
- Administrative duties including preparing for meetings and writing minutes
- Has attention to details, able to work accurately, identifying errors quickly and easily
- Has a planned and organised approach with an ability to priority their own workload to meet strict deadlines
- Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience
- An excellent understanding of data protection and confidentiality issues
- Self-motivated, pro-active and able to work independently
- Continued commitment to improve skills and abilities in new areas of work
- Able to undertake the demands of the post with reasonable adjustment if required
- Able to access transport to work across the practices within the PCN and attend meetings in other locations
- Excellent time keeping and prioritisation skills
- Professional attributes and appearance
- Excellent IT skills and the ability to run reports and interpret and analyse and present data
Desirable
- Understanding of medical technology around frailty, population health management and long term conditions
Other requirements
Essential
- Flexibility to work outside of core office hours including extended hours services
- Disclosure Barring Service DBS check
- Hold a Valid UK Driving License and have access to own transport with business insurance and ability to travel across the locality on a regular basis, including visiting people in their own home or care home.
Qualifications
Essential
- GCSE grade A-C in Maths and English or skills level 2 in Maths and English or equivalent
Desirable
- ECDL or other equivalent IT qualification
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.
