Job summary
An exciting opportunity has arisen to recruit an
additional Care Coordinator within the South Peterborough Primary Care Network
(SPPCN). This role will play a critical function in supporting the PCN to
successfully implement a high-profile project focused on improving patient care
and outcomes. We are seeking dedicated individuals to join our team and provide
exceptional care coordination services to our patients. As a Care Coordinator,
you will work closely with GPs and other primary care professionals to identify
and manage a caseload of patients, ensuring their needs are met and appropriate
support is provided.
Please find below a link for further information on the
Care Coordinator role: https://www.youtube.com/watch?v=l-2-UJTAPNI
Please note that this is a part time role offering 30 hours per week.
Main duties of the job
- Proactively identify and work with a
cohort of people to support their personalised care requirements, ensuring an
understanding of what matters to them when developing their personalised care
and support plans in line with PCSP best practices;
- Coordinating patient healthcare by working
closely with the patient and their clinician to ensure they receive the most
suitable care and are directed to appropriate services;
- Assisting patients in managing their needs,
answering queries, and supporting them in making appointments;
- Supporting patients in accessing education,
training, employment opportunities, and appropriate benefits;
- Promoting shared decision-making and
providing decision support tools to help patients be better prepared for
conversations with healthcare professionals;
- Providing patients with high-quality
information to facilitate informed choices about their care;
- Assisting eligible individuals in accessing
personal health budgets, when appropriate;
- Supporting the coordination and delivery of
Multi-Discipline Teams within PCNs;
- Managing referrals received
through the NHS App and directing them to the appropriate clinician or
professional group
About us
LAKESIDE HEALTHCARE is changing the face of primary care provision in
England. We are bold, adventurous, ambitious and determined to thrive in
uncertain times. We are the largest true partnership in the NHS and operate
from various sites across the East Midlands. We serve the healthcare needs of
over 170,000 patients across Northamptonshire, Lincolnshire, Cambridgeshire and
Peterborough, operating services for 4 Primary Care Networks (PCN) across our
geography. Joining our team presents an opportunity to be part of a large
organisation that is changing the way primary care is delivered today, focussed
on local needs at a PCN level. https://www.lakesidehealthcaregroup.co.uk/
About the
Practice/Department/Team
South Peterborough
PCN is a large, forward-thinking Primary Care Network compromising 4 practices
across north Cambridgeshire and Peterborough. We recognise the value that this
role can bring to our practices and our patients, and we look forward to
growing our PCN team. Our aim is to provide exemplary patient care; finding
innovative solutions in general practice to deliver the best care we can to our
patients.
South Peterborough PCN
consists of 4 practices Lakeside Yaxley, Lakeside New Queen Street, Old Fletton
Surgery and Wansford Surgery. For more information on primary care networks
please visit https://www.england.nhs.uk/primary-care/primary-care-networks/
Job description
Job responsibilities
Care coordinators provide extra time, capacity, and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the PCN to better identify and manage a caseload of selected 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 to reflect local priorities, health inequalities or population health management risk stratification, this will include support digital referral management, for example from the NHS App.
You will have a background in healthcare coordination, an understanding of projects and population health initiatives. In this role, you will be responsible for managing and coordinating care services, collaborating with multidisciplinary teams, and implementing processes to improve health outcomes for specific populations. You will play a crucial role in the success of our population health project and contribute to enhancing the overall well-being of our community.
Key responsibilities and tasks
You will
- Support and contribute to the population health project.
- Collect, analyse and interpret data related to population health, identifying trends, gaps in care and areas for improvement.
- Support project plans, timelines and milestones to ensure the successful execution of population health initiatives.
- Maintain accurate and up-to-date records of patient interactions, interventions, and outcomes, and generate reports to monitor project progress and outcomes.
- Stay informed about the latest developments in population health and apply this knowledge to improve project effectiveness.
- Proactively identify and work with a cohort of people to support their personalised care requirements, ensuring an understanding of what matters to them.
- Bring together all of a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice.
- Help people to manage their needs, answering their queries and supporting them to make appointments.
- Support people to take up training and employment, and to access appropriate benefits where eligible.
- Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision making conversation.
- Ensure that people have good quality information to help them make choices about their care.
- Support people to understand their level of knowledge, skills and confidence their Activation level when engaging with their health and wellbeing, including through use of the Patient Activation Measure.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
- Explore and assist people to access personal health budgets where appropriate.
- Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
- Support the coordination and delivery of Multi Discipline Teams within PCNs.
- Support the management of referrals received through the NHS App to the practice and direct to the appropriate clinician or professional group.
- Liaise with members across all practices within the PCN, supporting good communication.
- Refer through to the appropriate member of the team, and/or make referrals on behalf of the team.
- Support the co-ordination and delivery of multidisciplinary teams MDTs within the PCN, to include management and arrangement/planning of team meetings and producing reports as requested.
- Visit patients in community, home or care home setting to assess and discuss their care needs involving carers, as appropriate.
- Establish good working relationships with people employed in practices across the PCN to enable them to carry out their duties effectively. It is important that the skills of existing teams continue to be valued and their roles developed as agreed with the practice.
Training requirements
- The Personalised Care Institute will set out what training is available and expected for Care Coordinators.
Other
- Be willing to undertake travel to various locations to carry out duties of the post as required.
- To safeguard the health, well-being, and safety of the patients we work with, some of whom maybe classed as vulnerable people or adults at risk. In the event of a risk to a Patient becoming apparent or if concerns arise about a vulnerable persons welfare, to immediately report these concerns in line with the appropriate policy and procedure.
NB. In addition to these responsibilities, employees are required to carry out other duties as may be reasonably required. Lakeside Healthcare reserves the right to vary this job description from time to time in line with business needs.
Job description
Job responsibilities
Care coordinators provide extra time, capacity, and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the PCN to better identify and manage a caseload of selected 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 to reflect local priorities, health inequalities or population health management risk stratification, this will include support digital referral management, for example from the NHS App.
You will have a background in healthcare coordination, an understanding of projects and population health initiatives. In this role, you will be responsible for managing and coordinating care services, collaborating with multidisciplinary teams, and implementing processes to improve health outcomes for specific populations. You will play a crucial role in the success of our population health project and contribute to enhancing the overall well-being of our community.
Key responsibilities and tasks
You will
- Support and contribute to the population health project.
- Collect, analyse and interpret data related to population health, identifying trends, gaps in care and areas for improvement.
- Support project plans, timelines and milestones to ensure the successful execution of population health initiatives.
- Maintain accurate and up-to-date records of patient interactions, interventions, and outcomes, and generate reports to monitor project progress and outcomes.
- Stay informed about the latest developments in population health and apply this knowledge to improve project effectiveness.
- Proactively identify and work with a cohort of people to support their personalised care requirements, ensuring an understanding of what matters to them.
- Bring together all of a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice.
- Help people to manage their needs, answering their queries and supporting them to make appointments.
- Support people to take up training and employment, and to access appropriate benefits where eligible.
- Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision making conversation.
- Ensure that people have good quality information to help them make choices about their care.
- Support people to understand their level of knowledge, skills and confidence their Activation level when engaging with their health and wellbeing, including through use of the Patient Activation Measure.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
- Explore and assist people to access personal health budgets where appropriate.
- Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
- Support the coordination and delivery of Multi Discipline Teams within PCNs.
- Support the management of referrals received through the NHS App to the practice and direct to the appropriate clinician or professional group.
- Liaise with members across all practices within the PCN, supporting good communication.
- Refer through to the appropriate member of the team, and/or make referrals on behalf of the team.
- Support the co-ordination and delivery of multidisciplinary teams MDTs within the PCN, to include management and arrangement/planning of team meetings and producing reports as requested.
- Visit patients in community, home or care home setting to assess and discuss their care needs involving carers, as appropriate.
- Establish good working relationships with people employed in practices across the PCN to enable them to carry out their duties effectively. It is important that the skills of existing teams continue to be valued and their roles developed as agreed with the practice.
Training requirements
- The Personalised Care Institute will set out what training is available and expected for Care Coordinators.
Other
- Be willing to undertake travel to various locations to carry out duties of the post as required.
- To safeguard the health, well-being, and safety of the patients we work with, some of whom maybe classed as vulnerable people or adults at risk. In the event of a risk to a Patient becoming apparent or if concerns arise about a vulnerable persons welfare, to immediately report these concerns in line with the appropriate policy and procedure.
NB. In addition to these responsibilities, employees are required to carry out other duties as may be reasonably required. Lakeside Healthcare reserves the right to vary this job description from time to time in line with business needs.
Person Specification
Experience
Essential
- Experience coordinating with multiple stakeholder or individuals to meet specified outcomes. Experience providing advice/signposting. Experience of data collection and providing monitoring information to assess the impact of services. Experience of partnership / collaborative working and of building relationships across a variety of organisations including the voluntary sector
Desirable
- Experience of working with healthcare professionals and/or previous experience in the NHS or social care. Experience of using clinical systems such as SystmOne. Experience of supporting people. Experience of supporting service improvement
Qualifications
Essential
- NVQ Level 3 or equivalent and/or relevant basic/first level professional qualification or working towards this. Good level of education with GCSE Math and English Grade C or above (or equivalent)
Desirable
- Safeguarding level 3 in Adults & Children & Young People
Person Specification
Experience
Essential
- Experience coordinating with multiple stakeholder or individuals to meet specified outcomes. Experience providing advice/signposting. Experience of data collection and providing monitoring information to assess the impact of services. Experience of partnership / collaborative working and of building relationships across a variety of organisations including the voluntary sector
Desirable
- Experience of working with healthcare professionals and/or previous experience in the NHS or social care. Experience of using clinical systems such as SystmOne. Experience of supporting people. Experience of supporting service improvement
Qualifications
Essential
- NVQ Level 3 or equivalent and/or relevant basic/first level professional qualification or working towards this. Good level of education with GCSE Math and English Grade C or above (or equivalent)
Desirable
- Safeguarding level 3 in Adults & Children & Young People
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.
