Job summary
An exciting opportunity has arisen within Rural Warwickshire North Primary Care Network who are looking for a highly organised Care Coordinator
Offering 25 days holiday along with public bank holidays you will be working with a well established and supportive team.
Main duties of the job
Focusing on Digital and Frailty, the Care Coordinator will arrange MDT meetings and smooth running of integrated care within the team setting.The key role of the Care Coordinator will be to schedule the MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
Coordinate and manage the administrative functions of MDT meetings.
Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
Manage reporting required and associated within the DES specifications for required services.
Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.
Signpost team members, service users and carers to relevant services
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 and clinical skills.
About us
Rural Warwickshire North Primary Care Network is a well established supportive PCN within North Warwickshire. With four member practices are large enough to be effective and drive change and small enough to enable quick decisions. Working across six practices for 37.5 hours a week over five days, Monday to Friday. 5 weeks holiday as well as bank holidays.
Job description
Job responsibilities
Role description
Care Co-ordinators work closely with GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. They focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.
The Care Coordinator will be part of the Primary Care Network (PCN) Multi-Disciplinary Team (MDT) who will be responsible for managing the care of people registered with practices within a particular PCN. This will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population.
The post holder will require to work in different practices within the area so will require a degree of flexibility and a range of duties that may vary as the service develops.
The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions including learning disability and dementia as well as cancer patients. An ethos of promotion of independence and partnership-working is integral to this post.
Primary Duties and Areas of Responsibility
Multi-Disciplinary Teams
Overall responsibility for arranging PCN led MDT meetings (including the Care Home(s) MDT) and the smooth running of integrated care within the team setting. The key role of the Care Coordinator will be to schedule the MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
Coordinate and manage the administrative functions of MDT meetings.
Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
- Manage reporting required and associated within the DES specifications for required services.
- Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.
- Signpost team members, service users and carers to relevant services
Long-term conditions
- 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 and clinical skills.
- Explain the management of a patients pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms
- 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 and of the patients care plan, without requiring a further referral from the GP.
- 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.
- 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
- 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
Communication and collaborative working relationships
- Demonstrates ability to work as a member of a team.
- Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary.
- Actively work toward developing and maintaining effective working relationships both within and outside the PCN.
- Work with service users, PCN practices and partners e.g. Care Homes to ensure new referrals are logged and allocated
- Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT
- Provide background information about individuals for the MDT meetings
- Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public
Other responsibilities
- To act at all times in an anti-discriminatory manner
- To be able to plan and respond to workload according to operational priorities
- To support the delivery of these functions across wider locality areas where necessary
- To undertake any training required in order to maintain competency including mandatory training
- To contribute to, and work within a safe working environment.
- The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures
- The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.
- The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.
Special Working Conditions
The post-holder is required to travel independently between practice sites (including home visits for patients registered at network practices) and to attend meetings etc. hosted by other agencies.
Job description
Job responsibilities
Role description
Care Co-ordinators work closely with GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. They focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.
The Care Coordinator will be part of the Primary Care Network (PCN) Multi-Disciplinary Team (MDT) who will be responsible for managing the care of people registered with practices within a particular PCN. This will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population.
The post holder will require to work in different practices within the area so will require a degree of flexibility and a range of duties that may vary as the service develops.
The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions including learning disability and dementia as well as cancer patients. An ethos of promotion of independence and partnership-working is integral to this post.
Primary Duties and Areas of Responsibility
Multi-Disciplinary Teams
Overall responsibility for arranging PCN led MDT meetings (including the Care Home(s) MDT) and the smooth running of integrated care within the team setting. The key role of the Care Coordinator will be to schedule the MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
Coordinate and manage the administrative functions of MDT meetings.
Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
- Manage reporting required and associated within the DES specifications for required services.
- Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.
- Signpost team members, service users and carers to relevant services
Long-term conditions
- 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 and clinical skills.
- Explain the management of a patients pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms
- 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 and of the patients care plan, without requiring a further referral from the GP.
- 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.
- 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
- 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
Communication and collaborative working relationships
- Demonstrates ability to work as a member of a team.
- Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary.
- Actively work toward developing and maintaining effective working relationships both within and outside the PCN.
- Work with service users, PCN practices and partners e.g. Care Homes to ensure new referrals are logged and allocated
- Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT
- Provide background information about individuals for the MDT meetings
- Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public
Other responsibilities
- To act at all times in an anti-discriminatory manner
- To be able to plan and respond to workload according to operational priorities
- To support the delivery of these functions across wider locality areas where necessary
- To undertake any training required in order to maintain competency including mandatory training
- To contribute to, and work within a safe working environment.
- The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures
- The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.
- The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.
Special Working Conditions
The post-holder is required to travel independently between practice sites (including home visits for patients registered at network practices) and to attend meetings etc. hosted by other agencies.
Person Specification
Qualifications
Essential
Desirable
Person Specification
Qualifications
Essential
Desirable
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.