Job summary
Work within our network of GP Practices to provide a co-ordinated role for patient care planning.
The role will be GP facing, with the core responsibility being excellent patient care.
The aim of the role is to support individuals to manage their health and wellbeing and continue to
live independently in their own homes for as long as possible. To holistically support patients with
mild to severe frailty within the community.
Co-ordinate care packages for patients as identified by the GP across health, social care and mental
health as appropriate, providing a single-point of access for staff & service users, actively managing
patients care plan delivery.
[please find full JD in 'Supporting Information']
Main duties of the job
Facilitate smooth and planned discharge and handover between care settings across the health and
social care system, including GP, acute, community, and be responsible for facilitating inter-agency
communication and support
Identify and work with a list of named patients with the aim of encouraging independence, enablingpeople to remain at home, reducing unnecessary admissions to hospitals and supporting earlydischarge from hospital, improving the quality of care.
Work as essential team member within a multi-disciplinary clinical team.
About us
South Fulham PCN Co. are the newly formed company comprising of the seven member practices that make South Fulham PCN with a population of 63,000 residents. We are a forward thinking, can-do and ambitious team who aim to provide consistent, excellent healthcare for our patients and residents. We are excited to transition our PCN into its new phase of development and growth. This position is well suited to individuals who are enthusiastic about providing high quality support to primary care. Based within South Fulham PCN, you will work closely with GP Practices within the primary care network.
[please find full JD in 'Supporting Information']
Job description
Job responsibilities
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.
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.
[please find JD in 'Supporting Information']
Job description
Job responsibilities
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.
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.
[please find JD in 'Supporting Information']
Person Specification
Experience
Essential
- Coordination of services from a variety of organisations
- Communication and relationship building
- Experience in health or social care
- Experience of developing relationships with a wide variety of people
Desirable
- Experience of health and social care assessments
- Demonstrated successful outcomes delivery within determined timeframes
Qualifications
Essential
- Relevant degree or equivalent level of training and experience
- Evidence of consistent pattern of learning from education, training and experience
Desirable
- Qualification in health or social care allied profession
Skills & Knowledge
Essential
- Understanding of human needs physical, emotional, social
- Proven ability to recognise and manage risk
- Knowledge of the needs of vulnerable adults, safeguarding and the associated legislative framework
- Ability to understand budgetary requirements; ensure that packages are cost effective and value for money; and highlight inefficiencies.
- Understanding of basic health and social care terminology
- Good interpersonal skills
- Ability to communicate confidently with staff of all seniority levels
- Ability to work well across teams
- Good time management and prioritisations skills, ability to work to strict deadlines
- Ability to work on own initiative without direct supervision, understanding where clinical input is needed
- IT skills and experience in the use of Microsoft Excel
Desirable
- Familiarity with IT systems currently in use in health and social care settings
Person Specification
Experience
Essential
- Coordination of services from a variety of organisations
- Communication and relationship building
- Experience in health or social care
- Experience of developing relationships with a wide variety of people
Desirable
- Experience of health and social care assessments
- Demonstrated successful outcomes delivery within determined timeframes
Qualifications
Essential
- Relevant degree or equivalent level of training and experience
- Evidence of consistent pattern of learning from education, training and experience
Desirable
- Qualification in health or social care allied profession
Skills & Knowledge
Essential
- Understanding of human needs physical, emotional, social
- Proven ability to recognise and manage risk
- Knowledge of the needs of vulnerable adults, safeguarding and the associated legislative framework
- Ability to understand budgetary requirements; ensure that packages are cost effective and value for money; and highlight inefficiencies.
- Understanding of basic health and social care terminology
- Good interpersonal skills
- Ability to communicate confidently with staff of all seniority levels
- Ability to work well across teams
- Good time management and prioritisations skills, ability to work to strict deadlines
- Ability to work on own initiative without direct supervision, understanding where clinical input is needed
- IT skills and experience in the use of Microsoft Excel
Desirable
- Familiarity with IT systems currently in use in health and social care settings
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.
