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Wimborne and Ferndown PCN

Ageing Well Care Coordinator

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This job is now closed

Job summary

Wimborne and Ferndown PCN are looking for a keen individual to support our Ageing Well Nurse and PCN team in providing the best care to our patients. Our PCN includes the following practices: The Quarter Jack Surgery / The Old Dispensary, Walford Mill Medical Centre, Pennys Hill Practice and Orchid House Surgery.

The role of the Ageing Well Coordinator is to support the Ageing Well Nurse by supporting frail patients within our community. Job tasks can include coordinating visits, triaging tasks, completing administration tasks as required and helping to develop our Ageing Well service.

Main duties of the job

The role will include

  • Checking workload tasks and ensuring they are dealt with in a timely manner.
  • Triaging tasks and prioritising appointment booking for the Ageing Well Nurse.
  • Checking Practice's out of hour call lists to see if there are any servere frail patients which need a follow up.
  • Completing any administration tasks required by the Ageing Well Nurse.
  • You may be required to go on visits with the Ageing Well Nurse to take notes.
  • Maintain the Dorset Care Plan list and ensure patients on this register are reviewed annually.
  • Forming a good working relationship with our Care Homes.
  • Travelling between our 4 GP practices.

Additional opportunities which may develop with the role:

  • Ageing Well Coordinator to complete some Dorset Care Plan reviews after Ageing Well Nurse has completed the initial review.
  • Work with the PCN Administration Team to complete projects on Health Inequalities or other projects.

About us

Wimborne & Ferndown PCN provides services to 42,000 patients across 4 Practices (Quarter Jack Surgery/ Old Dispensary, Walford Mill Medical Centre, Pennys Hill Practice, Orchid House Surgery). We have adopted new roles within the PCN to support and broaden our primary care team which allows us to provide better care for our patients.

The PCN is headed by our committed Clinical Directors and a PCN Manager.

In addition to the PCN, our Practices are also part of Castleman Healthcare, a non-profit company owned by 13 GP Practices in North Poole and East Dorset (3 PCNs). Castleman Healthcare offer additional services to our Patients through separate contracting arrangements, provide business and practical support to the PCNs and support with representing the PCNs voice within the wider healthcare system.

Details

Date posted

19 April 2024

Pay scheme

Other

Salary

£11.77 an hour

Contract

Permanent

Working pattern

Full-time, Part-time

Reference number

A5332-24-0000

Job locations

Rodways Corner

Wimborne

Dorset

BH21 1AP


Ferndown Medical Centre

St. Marys Road

Ferndown

Dorset

BH22 9HB


Job description

Job responsibilities

Key duties

To methodically action the elements of the project plan against nationally set criteria including but not limited to:

Support the Ageing Well and Enhanced Health in Care Homes Project Plans

Work through the elements of the project plans, aligning practice-based work with PCN and national directives.

Ensure key deliverables are on-track, managed and provided to patients.

Be the champion across the Network for the Ageing Well and Care Home projects.

Link practices, patients, the Network, community and hospital services together by being the conduit to the Network and the practices.

Urgent Community Response

Be the link between the Network and the community provider.

Personalised Care and Support Plans

Maintain a system to ensure that all current and new care home residents have a care plan in place that is updated regularly by appropriate individuals such as GPs, ANPs, Nurses, community teams, care home staff.

Assess the need for care plans to be put in place in the wider community for those patients living outside of care homes.

Help professionals, cares and individuals navigate the health and care system

Be the first port of call for queries and problems relating to the navigation of systems. Help guide, direct and support patients and their carers.

Palliative and end of life care

Design and instigate a robust system of ensuring palliative patients are raised by the practice, discussed and MDT. Ensure patients are on the Gold Standard Framework, ensure care plans are in place shared appropriately. Ensure care homes can access palliative care support. Set up training sessions for care home staff to support their palliative patients.

Mental health and Dementia Care

Ensure care plans have appropriate mental health sections within them. Research DiADEM and DEAR-GP as a means to support patients with dementia.

Project work

Work with the PCN Administration Team to target unwarranted health outcomes and using the local infrastructure (such as the Social Prescriber) to improve the health of the targeted population using recognised Population Health Management tools (such as the DiiS or Electronic Frailty register.).

Job description

Job responsibilities

Key duties

To methodically action the elements of the project plan against nationally set criteria including but not limited to:

Support the Ageing Well and Enhanced Health in Care Homes Project Plans

Work through the elements of the project plans, aligning practice-based work with PCN and national directives.

Ensure key deliverables are on-track, managed and provided to patients.

Be the champion across the Network for the Ageing Well and Care Home projects.

Link practices, patients, the Network, community and hospital services together by being the conduit to the Network and the practices.

Urgent Community Response

Be the link between the Network and the community provider.

Personalised Care and Support Plans

Maintain a system to ensure that all current and new care home residents have a care plan in place that is updated regularly by appropriate individuals such as GPs, ANPs, Nurses, community teams, care home staff.

Assess the need for care plans to be put in place in the wider community for those patients living outside of care homes.

Help professionals, cares and individuals navigate the health and care system

Be the first port of call for queries and problems relating to the navigation of systems. Help guide, direct and support patients and their carers.

Palliative and end of life care

Design and instigate a robust system of ensuring palliative patients are raised by the practice, discussed and MDT. Ensure patients are on the Gold Standard Framework, ensure care plans are in place shared appropriately. Ensure care homes can access palliative care support. Set up training sessions for care home staff to support their palliative patients.

Mental health and Dementia Care

Ensure care plans have appropriate mental health sections within them. Research DiADEM and DEAR-GP as a means to support patients with dementia.

Project work

Work with the PCN Administration Team to target unwarranted health outcomes and using the local infrastructure (such as the Social Prescriber) to improve the health of the targeted population using recognised Population Health Management tools (such as the DiiS or Electronic Frailty register.).

Person Specification

Qualifications

Essential

  • GCSE A-C in English and Maths

Desirable

  • HCA Experience (e.g. qualified in phlebotomy)

Experience

Essential

  • Experience and/or knowledge of the NHS and Care Homes.
  • Data management and analysis skills.
  • Awareness of confidentiality and ability to deal appropriately with sensitive or difficult situations.
  • Ability to manage change working with Partners, Managers and Stakeholders.
  • Ability to act as a role model demonstrating effective behaviour and leading by example.
  • Ability to manage various projects in a timely manner.
  • Flexible, versatile, and self-motivated.
  • Effective communicator at all levels
  • Ability to work as part of a team or on own projects
  • Open minded and positive, focused on solutions not problems, a can do attitude.
  • Flexible working attitude
  • Demonstrate a high level of integrity and ingenuity
  • Be a strategic thinker with an ability to be innovative
  • Able to lead and inspire others

Desirable

  • Healthcare Assistant Experience.
  • SystmOne Knowledge.
Person Specification

Qualifications

Essential

  • GCSE A-C in English and Maths

Desirable

  • HCA Experience (e.g. qualified in phlebotomy)

Experience

Essential

  • Experience and/or knowledge of the NHS and Care Homes.
  • Data management and analysis skills.
  • Awareness of confidentiality and ability to deal appropriately with sensitive or difficult situations.
  • Ability to manage change working with Partners, Managers and Stakeholders.
  • Ability to act as a role model demonstrating effective behaviour and leading by example.
  • Ability to manage various projects in a timely manner.
  • Flexible, versatile, and self-motivated.
  • Effective communicator at all levels
  • Ability to work as part of a team or on own projects
  • Open minded and positive, focused on solutions not problems, a can do attitude.
  • Flexible working attitude
  • Demonstrate a high level of integrity and ingenuity
  • Be a strategic thinker with an ability to be innovative
  • Able to lead and inspire others

Desirable

  • Healthcare Assistant Experience.
  • SystmOne Knowledge.

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.

Employer details

Employer name

Wimborne and Ferndown PCN

Address

Rodways Corner

Wimborne

Dorset

BH21 1AP


Employer's website

https://www.quarterjacksurgery.co.uk/ (Opens in a new tab)

Employer details

Employer name

Wimborne and Ferndown PCN

Address

Rodways Corner

Wimborne

Dorset

BH21 1AP


Employer's website

https://www.quarterjacksurgery.co.uk/ (Opens in a new tab)

Employer contact details

For questions about the job, contact:

PCN Manager

Megan Berry

megan.berry@dorsetgp.nhs.uk

Details

Date posted

19 April 2024

Pay scheme

Other

Salary

£11.77 an hour

Contract

Permanent

Working pattern

Full-time, Part-time

Reference number

A5332-24-0000

Job locations

Rodways Corner

Wimborne

Dorset

BH21 1AP


Ferndown Medical Centre

St. Marys Road

Ferndown

Dorset

BH22 9HB


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