Job summary
CARE COORDINATOR - Full-Time (37.5 hours / week)
Job
Title: Care Coordinator
Reports
to: Operations
Manager
Accountable
to: Operations Manager, Albany House
Partnership, Practice Safeguarding lead, Wellingborough PCN manager and
clinical
Directors
The successful candidate will be required to work across Albany House Medical Centre and Irchester & Summerlee Medical Centre
Main duties of the job
The post holder will deliver
high quality wellbeing services. The role involves managing a caseload to meet
the health and wellbeing needs of the patients. The focus will be in supporting
the assessment and treatment to people living with mental health/wellbeing
needs/learning disabilities/Cancer, and their carers.
The post holder will have the confidence to work across Primary, Secondary, and Community services.
The Care Coordinator will refer
people back to other health professionals within the PCN utilising existing IT
and MDT channels to screen patients, with an aim of identifying those that
would benefit most from the services on offer and supporting external referrals
when appropriate.
The post holder will provide administrative support to the practices to achieve a consistent, safe and effective team approach to providing a service to our service users.
To support the Practice with QOF and DES / LES work as directed by the
clinical leads. Have an overview of the current call/recall situation and ensure patients are called in a timely manner.
Coordinate and complete care plans with the relevant lead
clinicians. Identify and work with vulnerable patient groups and their carers
to ensure adequate support is provided.
Organise meetings with key
professionals.
Fulfil other administrative duties as required to aid the smooth running of the practice.
About us
ABOUT ALBANY HOUSE MEDICAL CENTRE, OUR VALUES AND BEHAVIOURS
Our purpose is to deliver the best possible care for all the people who visit our practices, either as patients, the public or as staff.
As one of the largest and busiest surgeries in Wellingborough, our vision is to move from where we are now to where we want to be, the journey from good to great.
In undertaking this role you are expected at all times to behave in accordance with our practice values which demonstrate your commitment to the delivery of high quality services to patients. This will be in accordance with agreed objectives, quality standards, and resource constraints.
Our values are:
- We treat patients, service users, and each other with kindness, dignity and respect
- Services are always designed around the Patient
- We deliver services that are well managed, efficient, convenient and accessible for patients
- We do what we say we are going to do
- We are one team and work best when we work together
Job description
Job responsibilities
Key Working Relationships
- Patients / members of the public
- GPs, Registrars and medical students
- Practice Staff
- Local Health Authorities
- District Nurses
- Health Visitors and Midwives
- Community and Practice Clinical Pharmacists
- Social Prescribers
- Age Well/Age UK and other Primary Care Network
assets
- CCG Safeguarding nurse for primary
care
- 0-19 nursing team (health visitor
& school nurses)
- Community midwife
- MASH health
- MARAC health
- MAPPA coordinator
- Early Help
- Acute
and community trust safeguarding leads
KEY DUTIES:
Safeguarding
Help the practice
to ensure safeguarding policies and procedures are up to date and consistent
with agreed best practice as defined by local and national guidelines.
Support the
practice in developing/accessing appropriate role-based training for members
of staff. Help the practice run training events which encourage a
multidisciplinary approach to safeguarding.
Provide advice
and training on the recording and coding of safeguarding relevant information
within the electronic patient record. Support the preparation of timely,
relevant, and proportionate safeguarding reports.
Facilitate the
implementation of templates and other decision support tools to support best
practice in safeguarding, as recommended by the Northamptonshire safeguarding
team and audit the use of same.
Support the
practice in achieving CQC compliance with respect to the safeguarding of
staff and patients.
Take a key role
in the development and running of an effective practice safeguarding MDT for
children and vulnerable adults. Ensure that the practice has a vulnerable
patient register which is kept up to date.
Help the practice
foster effective relationships with local safeguarding partners. Ensure the
timely sharing of relevant information, both verbally and in a structured
report, when safeguarding concerns arise in respect of both children and
adults.
Support the
practice in responding to statutory requests for information required by the local
authority to carry out local child or adult safeguarding case reviews and
assist the practice with section 42 enquiries. Disseminate learning and
support the implementation of review recommendations.
Undertake regular
audits as requested by line manager and present at educational meetings to
ensure compliance and enhance education
Promote the
understanding of local safeguarding referral pathways, including Early Help
and support services for victims of domestic abuse.
Attend meetings and training sessions (internal and external) in regards to safeguarding matters, representing the practice and sharing knowledge and information as required.
QOF/LES/DES Reviews
- Identify patients who fall within national and
practice criteria
- Call/Recall patients in a timely manner
- Perform initial telephone/video/face to face
assessments
- Liaise with usual GP with any area of concern
- Update SystmOne care plans as appropriate
- Coordinate referrals to social prescribers
- Work with Wellingborough PCN teams for
patient care plans and reviews
- Where appropriate work with clinicians to
discuss escalation care plans and where required end of life preferences with patients
and their carers
- Coordinate any safeguarding concerns with the
practice safeguarding leads and attend internal safeguarding meetings
Action Discharge summaries
- Review hospital discharge summaries for
adults, families, carers (excluding care homes)
- Code admission and reason
- Contact the patient within 48 hours of
discharge to offer support and discuss care needs. Signpost to services as
appropriate i.e. Practice social prescriber, clinical pharmacist and local
frailty teams.
- Diarise to follow up with patient as
appropriate
- Liaise with usual GP with any area of concern.
- Where appropriate liaise with hospital staff
whilst patient is an inpatient and support to enable discharge
- Set up a spreadsheet to record contacts and
outcomes
- Audit hospital admissions in 3 months to
identify any common themes, frequent flyers
- Attend meetings as and when required including
MDT, Practice meetings
- Provide a quarterly update to CCG as per
contract July, October, January and April
This
list is not exhaustive and any tasks/roles that will
assist the practice may be required.
Job description
Job responsibilities
Key Working Relationships
- Patients / members of the public
- GPs, Registrars and medical students
- Practice Staff
- Local Health Authorities
- District Nurses
- Health Visitors and Midwives
- Community and Practice Clinical Pharmacists
- Social Prescribers
- Age Well/Age UK and other Primary Care Network
assets
- CCG Safeguarding nurse for primary
care
- 0-19 nursing team (health visitor
& school nurses)
- Community midwife
- MASH health
- MARAC health
- MAPPA coordinator
- Early Help
- Acute
and community trust safeguarding leads
KEY DUTIES:
Safeguarding
Help the practice
to ensure safeguarding policies and procedures are up to date and consistent
with agreed best practice as defined by local and national guidelines.
Support the
practice in developing/accessing appropriate role-based training for members
of staff. Help the practice run training events which encourage a
multidisciplinary approach to safeguarding.
Provide advice
and training on the recording and coding of safeguarding relevant information
within the electronic patient record. Support the preparation of timely,
relevant, and proportionate safeguarding reports.
Facilitate the
implementation of templates and other decision support tools to support best
practice in safeguarding, as recommended by the Northamptonshire safeguarding
team and audit the use of same.
Support the
practice in achieving CQC compliance with respect to the safeguarding of
staff and patients.
Take a key role
in the development and running of an effective practice safeguarding MDT for
children and vulnerable adults. Ensure that the practice has a vulnerable
patient register which is kept up to date.
Help the practice
foster effective relationships with local safeguarding partners. Ensure the
timely sharing of relevant information, both verbally and in a structured
report, when safeguarding concerns arise in respect of both children and
adults.
Support the
practice in responding to statutory requests for information required by the local
authority to carry out local child or adult safeguarding case reviews and
assist the practice with section 42 enquiries. Disseminate learning and
support the implementation of review recommendations.
Undertake regular
audits as requested by line manager and present at educational meetings to
ensure compliance and enhance education
Promote the
understanding of local safeguarding referral pathways, including Early Help
and support services for victims of domestic abuse.
Attend meetings and training sessions (internal and external) in regards to safeguarding matters, representing the practice and sharing knowledge and information as required.
QOF/LES/DES Reviews
- Identify patients who fall within national and
practice criteria
- Call/Recall patients in a timely manner
- Perform initial telephone/video/face to face
assessments
- Liaise with usual GP with any area of concern
- Update SystmOne care plans as appropriate
- Coordinate referrals to social prescribers
- Work with Wellingborough PCN teams for
patient care plans and reviews
- Where appropriate work with clinicians to
discuss escalation care plans and where required end of life preferences with patients
and their carers
- Coordinate any safeguarding concerns with the
practice safeguarding leads and attend internal safeguarding meetings
Action Discharge summaries
- Review hospital discharge summaries for
adults, families, carers (excluding care homes)
- Code admission and reason
- Contact the patient within 48 hours of
discharge to offer support and discuss care needs. Signpost to services as
appropriate i.e. Practice social prescriber, clinical pharmacist and local
frailty teams.
- Diarise to follow up with patient as
appropriate
- Liaise with usual GP with any area of concern.
- Where appropriate liaise with hospital staff
whilst patient is an inpatient and support to enable discharge
- Set up a spreadsheet to record contacts and
outcomes
- Audit hospital admissions in 3 months to
identify any common themes, frequent flyers
- Attend meetings as and when required including
MDT, Practice meetings
- Provide a quarterly update to CCG as per
contract July, October, January and April
This
list is not exhaustive and any tasks/roles that will
assist the practice may be required.
Person Specification
Experience
Essential
- - Experience of working within a healthcare team
- - Experience of dealing with vulnerable patient
Desirable
- - Experience of working in primary care
- - Experience of working in a GP practice
- - Experience of utilising SystmOne
- - knowledge of QOF and DES/LES requirements
Qualifications
Essential
- - GCSE grade A to C in English and Maths
Desirable
- - Qualified to NVQ level 2 in Health and Social Care
Person Specification
Experience
Essential
- - Experience of working within a healthcare team
- - Experience of dealing with vulnerable patient
Desirable
- - Experience of working in primary care
- - Experience of working in a GP practice
- - Experience of utilising SystmOne
- - knowledge of QOF and DES/LES requirements
Qualifications
Essential
- - GCSE grade A to C in English and Maths
Desirable
- - Qualified to NVQ level 2 in Health and Social Care
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.
