Job responsibilities
Main Duties and Responsibilities
To obtain data and information for the PCN to:
- Increase the health and wellbeing of the frail and care home patients
- Assess the Extended PACT model made by the PCN, and be able fully utilize the model to reduce hospital admissions.
- Contribute as a team member to supporting other staff employed in the PCN to carry out the delivery of the objectives using data.
- The Care coordinator will work with the Primary Care Network Operations Manager/Clinical Director, Public Health Teams and CCG to obtain the PCN baseline measures for the identified specialties.
- Attend monthly MDT meetings on behalf of the surgeries to discuss and coordinate care for vulnerable patients.
- Act as the first point of contact for new referrals into the Integrated Neighbourhood Team.
- Triage and assess patient needs, ensuring timely allocation to the most appropriate service.
- Work collaboratively with clinicians, social care teams, and voluntary sector partners.
- Maintain accurate and up-to-date patient records using relevant systems.
- Contribute to multidisciplinary team (MDT) meetings and case discussions.
- Support proactive, holistic care planning for patients with complex health or social needs.
- Liaise with Primary Care Networks (PCNs) to support population health priorities and integrated working.
Data Collection
- Set up and run SystmOne searches, under the instruction of the Primary Care Network Operations Manager, Public Health and the Clinical Directors, to identify the PCN needs and also to monitor progress against indicators.
- Collect audit data by interviewing patients and/or staff as required.
- Retrieve data from information systems and clinical documentation for the purpose of undertaking clinical audit (consistent with the audit measures and data collection instructions) or support clinical staff carrying out these functions directly.
- Set up databases and spreadsheets for the collection of audit data and enter audit data as required, such as using a spreadsheet for current PCN projects.
- Check the accuracy, completeness and timeliness of data entered in to a database or spreadsheet for a clinical audit and advise relevant people of missing or inaccurate data or an impending deadline for submission of complete and accurate data.
- Analyse or assist clinical staff in analysing audit data appropriately so that the level of compliance with best practice can be determined and the results used to prompt changes in practice as necessary.
Contributing to carrying out work needed to ensure that the PCN meets external requirements related to clinical audit.
- Maintain documentation related to clinical audit consistent with approved policies, the Data Protection Action, General Protection Data Regulations (GDPR) and Human Rights Act and ensure that the information is available for reporting purposes.
- Record progress of clinical audit activity on the PCN database systems ensuring that there is a detailed, timely and accurate record of all allocated projects. This will include evidence of improvements achieved through clinical audit.
Contribute to supporting the smooth running of the Primary Care Network.
- Attend meetings as required and any other local or regional audit meetings pertaining to Population Health or Health Inequalities as requested by the PCN Manager or Clinical Director.
- Attend meetings with the other PCN Clinical Audit Team for the purpose of reviewing the departmental activity and sharing general information.
Communication
Communicate effectively with other team members;
Communicate effectively with patients and carers, recognising their needs for alternative methods of communication;
Enthusiastic about health promotion and lifestyle change.
Personal and people development
Take responsibility for own developmental learning and performance, including participating in supervision;
Take responsibility for maintaining a record of own personal development;
Work with management on any new training requirements;
To recognise and understand the roles and responsibilities of individuals working in the primary health care team.
Health, safety and security
Use the personal security systems within the workplace according to practice guidelines;
Identify the risks involved in work activities and undertake them in a way that manages the risks;
Know the health and safety policies and procedures within the workplace, including fire procedures, maintaining documentation, monitoring and maintaining of equipment and furniture within their area of responsibility;
Use the computer monitor safely.
Service improvement
Work with colleagues in the team on the development of current and new services and other initiatives;
Work closely with the Physician Associate and Healthcare Assistant to identify areas of need for Canvey Island PCN.
Quality
Alert other team members to issues of quality and risk in the care of patients;
Ensure own actions are consistent with clinical governance systems;
Know the organisations policies, especially the whistle-blowing policy, available in the practice staff handbook;
Be able to manage their own time effectively.
Equality and diversity
Act in ways that recognise the importance of people's rights, interpreting them in a way that is consistent with procedures;
Respect the privacy, dignity, needs and beliefs of patients and carers;
Information processes
Maintain confidentiality or information relating to patients, relatives, staff and the PCN;
Maintain accurate and contemporaneous electronic patient records on SystmOne;
Take the necessary precautions when transmitting information.
Duties and Responsibilities:
Attend annual updates and mandatory training as required;
Highlight any gaps in knowledge/training needs to their line manager to allow them the opportunity to offer support in order to fulfil the duties of this post;
Act in a manner that safeguards children and/or vulnerable adults as applicable to the role;
Work in line with organisational policies and procedural guidelines.
This JD is not intended to be an exhaustive list of activities but rather an outline of the main areas of responsibility. The role is likely to evolve to meet the changing needs of the service.
