Leek and Biddulph PCN

Care Co-ordinator

This job is now closed

Job summary

This role will be part of the Multi-Disciplinary Team (MDT) at Leek and Biddulph PCN, working with colleagues across the Primary Care Network. Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly, those with learning disabilities and long-term conditions, to provide coordination and navigation of care and support across health and care services.

PCNs have new responsibilities for improving health inequalities and providing additional care/services to their populations. Key responsibilities of our PCN include the provision of support and enhanced care to vulnerable patients and patients in residential and nursing home settings and this will be an integral part of this role.

The post holder will support members of the Practice in co-ordinating all key activity including access to services, advice, and information, and ensuring health and care planning is timely, efficient, and patient-centred.

Main duties of the job

To take referrals for individuals or proactively identify people who could benefit from support through care coordination.

Act as a point of contact between GP, patients and carers and other agencies.

Liaise with GPs and practice teams to identify patients who are elderly, frail or who have learning disabilities or long term health needs and support.

To work closely with GPs and practice teams, making sure that appropriate support is made available to people; supporting them to understand and manage their condition and ensuring their changing needs are addressed. They will enable people to access the services and support they require to meet their health and wellbeing needs, helping to improve peoples quality of life.

To focus on the existing registers of patients with long term conditions and ensure these are up to date and ensuring these individuals have access to the reviews and appointments they need to support them to manage their conditions effectively.

To proactively identify and support the practice patients with long term conditions to access appropriate appointments and care.

Use the EMIS Web searches to identify the appropriate patients and invite them for their annual care review. Implement and contribute to the call and recall process

Contribute to the support and care for cancer patients, patients with dementia and those with long term conditions.

About us

Leek and Biddulph PCN are a group of five GP practices working together to focus on local patient care. We are a multi-disciplinary team, covering Leek and Biddulph, responsible for the healthcare of just over 50,000 patients. We are led by Dr Neil Briscoe our PCN Clinical Director and a supportive management team.

We are a very forward thinking and innovative PCN who have recently become the first PCN in North Staffordshire to convert to a Limited Company. We utilise to the full, the skills and experience of our team members which includes Clinical Pharmacists, Pharmacy Technicians, Occupational Therpaists, Dietitians, Physiotherapists, Social Prescribers and a Mental Health Practitioner. We have a flexible approach to working patterns and generous terms and conditions including the NHS Pension.

We are supportive of professional development and pride ourselves on developing new roles in a collaborative and friendly environment

Date posted

09 July 2024

Pay scheme

Other

Salary

£25,147 a year Pro rata for part time

Contract

Permanent

Working pattern

Full-time, Part-time, Flexible working

Reference number

A5111-24-0004

Job locations

Biddulph Primary Care Centre

Wharf Road

Biddulph

Stoke-on-trent

ST8 6AG

Job description

Job responsibilities

We are looking for someone who is empathetic, organised with great interpersonal skills who will be committed to delivering the highest quality of service to our patients.

If you have what it takes and have the experience as follows, we would like to hear from you:

Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work).

Experience of supporting people, their families and carers in a related role (including unpaid work).

Excellent IT skills including advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports.

Willingness to undertake further professional development.

Working in a multi-disciplinary setting where influence and negotiation is required.

Creative problem solver and willing to search for hard-to-find information.

Access to own transport and ability to travel across the locality on a regular basis

The role will involve working across any of our 5 local practices and Care Homes within our patch and occasional travel further afield.

Key roles:

Use the EMIS Web searches to identify the appropriate patients and invite them for their annual care review. Implement and contribute to the call and recall process

Ensure all relevant patients are supported and encouraged to attend their annual reviews including conversations with those patients who regularly decline this support.

Contribute to the support and care for cancer patients, patients with dementia and those with long term conditions.

Act as the first port of call for care homes and our Multi-Disciplinary ARRS team.

Work with the multi-disciplinary team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.

Provide these cohorts of people signposting to identified services in order to maintain their independence and improve their health and well being.

Visit patients in community, home or care home settings to assess and discuss their care needs involving carers as appropriate

Ensure regular and consistent communication with care homes regarding patient progress and any complications.

Assist with personal care plans for individual patients, ensuring preventative actions are detailed to support the appropriate use of services.

Communicate the care plan to the GP and any other professionals involved in the persons care and upload to the relevant records.

Ensure that identified patients receive the right level of help at the right time and help them to experience a joined up service by liaising with relevant Organisations.

Work with patient, carers and healthcare team members to encourage the patient to adopt effective self-management and self-help seeking approaches to reduce unnecessary Hospital admissions.

Liaise with other agencies, Primary, Secondary and specialist care services to ensure timely and appropriate engagement as required.

Support patients to access community care assessments as well as carers assessments.

Identify unpaid carers and direct them to access services as appropriate to provide them with support.

Identify when urgent action or a step up in care is required and promptly alert the relevant professionals involved, highlighting any safety concerns.

Follow up on communications from out of hospital and in-patient services regarding changes in condition of patients to support the practice to respond proactively to potentially unmet needs.

Undertake visits or telephone contact to manage patients on the PCNs case load following any unplanned hospital admissions where appropriate.To attend multi-disciplinary meetings plus any other meetings where there is a need to discuss patients on case load. Updates between meetings to be shared with the Practices.

Undertake visits or arrange appointments at their Practice for patients on the PCNs case load or otherwise as directed by the Practices following identification of urgent and non-urgent clinical need to assess, diagnose, treat, prescribe and refer appropriately according to the patients health needs and acting within the PCNs clinical skill set.

Maintain accurate and up to date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e. entering notes onto EMIS using agreed read codes.

To run regular patient searches using EMIS in order to have an up to date record of progress of achievement of Key Performance Indicators.

Support the PCN in providing KPI reports for submission as requested.

Support practices with their workload under FAAS, including identifying patients that require Care Plans.

Ensure all patients under the FAAS have a fully completed care plan, liaising with patients and clinicians where appropriate.