Job summary
Newcastle
South Primary Care Network (PCN) comprises
of 6 separate member GP Practices working together to provide patient care to a
population of just over 43,000.
The PCN continues to deliver innovative services to meet the
needs of our local population. As part
of our on-going development an exciting opportunity has arisen for a Care
Coordinator to join our team.
Your role
will be integral when it comes to delivering the best patient care, and the
successful candidate will possess strong administrative skills with the ability
to multi-task and have a keen eye for detail. You will need the ability to
communicate well with patients as you will often be the first point of contact
for the frailty services. You must be
able to listen to patients and demonstrate empathy putting them at ease.
Main duties of the job
The role will be to provide
holistic assessments under the Facilitation of Admission Avoidance Scheme. The assessments will be face to face and
given the patient cohort will predominantly be completed in the patients homes
or in clinic. The post holder will be
expected to:
-
Develop, implement
and review personalised care plans that meet physical, emotional and social
needs of frail older adults
-
Identify early signs
of deterioration and implement proactive interventions to avoid hospital
admissions where appropriate
-
Promote
self-management and independence in patients with long term conditions
-
Support in advanced
care planning conversations where appropriate
-
Co-ordinate access
to additional services, team members and care packages as appropriate
About us
Newcastle South PCN is made up of 6 member GP
Practices with a combined patient population of circa 43,000. The practices are from both urban and rural
areas, with significantly differing patient demographics:
Silverdale Medical Centre
Madeley Practice
Kingsbridge Medical Centre
University of Keele Practice
Betley Surgery
Ashley Surgery
We
are a dynamic and forward thinking PCN team comprising of Clinical Pharmacists,
Pharmacy Technicians, Care Coordinators, Social Prescribing Link Workers, First
Contact Physiotherapy and Mental Health Practitioners, Health and Wellbeing
Coach and GP.
Job description
Job responsibilities
CARE CO-ORDINATOR JOB DESCRIPTION
Salary: Equivalent to NHS Band 4
Hours of work: Full Time (30 hours per week)
Temporary for 6 months with potential for contract to be extended
Reports to: PCN Care Coordinator Team Leader
Responsible to: PCN Strategic Business Manager
Location: Required to work across multiple locations.
The role will be to provide holistic assessments under the Facilitation of Admission Avoidance Scheme. The assessments will be face to face and given the patient cohort will predominantly be completed in the patients homes or in clinic. The post holder will be expected to:
- Develop, implement and review personalised care plans that meet physical, emotional and social needs of frail older adults
- Identify early signs of deterioration and implement proactive interventions to avoid hospital admissions where appropriate
- Promote self-management and independence in patients with long term conditions
- Support in advanced care planning conversations where appropriate
- Co-ordinate access to additional services, team members and care packages as appropriate
Key Service Responsibilities:
- Contribute to the long term condition reviews of patients within primary care as part of the multi-disciplinary team within the practice
- Undertake Assessments under the Facilitation of Admission Avoidance Scheme.
- Contribute to the delivery of long term condition clinics as and when required, through providing basic patient care such as phlebotomy, blood pressure and measurements
- Work alongside our team of Care Co-ordinators to ensure that all patients are effectively accessing care in accordance with their needs and wishes
- Help patients to manage their needs through answering queries, making and managing appointments, and ensuring that patients have good quality written or verbal information to help them make choices about their care
- Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level
- Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals
- Support the coordination and delivery of MDTs across the PCN
Facilitation of Facilitation of Admission Avoidance Scheme
- Identify eligible patients from a specified cohort
- Ensure clinics are fully booked with identified patients
- Carry out face to face assessments.
- Ensure case management and care plans are written up and recorded at the end of each appointment, ensuring any referrals or actions are facilitated.
Administrative Responsibilities:
- Work with the GPs and other primary care professionals within the PCN to identify patients requiring access to phlebotomy
- Raise awareness within the PCN of the service and how to access it
- To work as a key member of the MDT to help support the development of effective MDT meetings.
- To ensure that action points identified within the MDT are recorded and followed up
Personal/Professional development:
- Participate in any training programme implemented by the PCN as part of this employment, such training to include:
- Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
- Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work
- To work in accordance with health and safety policies and procedures including reporting and recording any health and safety incident or accident
- Adhere to host employers adult and children safeguarding policies and procedures
This job description is not exhaustive, and duties may vary with the requirements of the PCN
Job description
Job responsibilities
CARE CO-ORDINATOR JOB DESCRIPTION
Salary: Equivalent to NHS Band 4
Hours of work: Full Time (30 hours per week)
Temporary for 6 months with potential for contract to be extended
Reports to: PCN Care Coordinator Team Leader
Responsible to: PCN Strategic Business Manager
Location: Required to work across multiple locations.
The role will be to provide holistic assessments under the Facilitation of Admission Avoidance Scheme. The assessments will be face to face and given the patient cohort will predominantly be completed in the patients homes or in clinic. The post holder will be expected to:
- Develop, implement and review personalised care plans that meet physical, emotional and social needs of frail older adults
- Identify early signs of deterioration and implement proactive interventions to avoid hospital admissions where appropriate
- Promote self-management and independence in patients with long term conditions
- Support in advanced care planning conversations where appropriate
- Co-ordinate access to additional services, team members and care packages as appropriate
Key Service Responsibilities:
- Contribute to the long term condition reviews of patients within primary care as part of the multi-disciplinary team within the practice
- Undertake Assessments under the Facilitation of Admission Avoidance Scheme.
- Contribute to the delivery of long term condition clinics as and when required, through providing basic patient care such as phlebotomy, blood pressure and measurements
- Work alongside our team of Care Co-ordinators to ensure that all patients are effectively accessing care in accordance with their needs and wishes
- Help patients to manage their needs through answering queries, making and managing appointments, and ensuring that patients have good quality written or verbal information to help them make choices about their care
- Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level
- Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals
- Support the coordination and delivery of MDTs across the PCN
Facilitation of Facilitation of Admission Avoidance Scheme
- Identify eligible patients from a specified cohort
- Ensure clinics are fully booked with identified patients
- Carry out face to face assessments.
- Ensure case management and care plans are written up and recorded at the end of each appointment, ensuring any referrals or actions are facilitated.
Administrative Responsibilities:
- Work with the GPs and other primary care professionals within the PCN to identify patients requiring access to phlebotomy
- Raise awareness within the PCN of the service and how to access it
- To work as a key member of the MDT to help support the development of effective MDT meetings.
- To ensure that action points identified within the MDT are recorded and followed up
Personal/Professional development:
- Participate in any training programme implemented by the PCN as part of this employment, such training to include:
- Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
- Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work
- To work in accordance with health and safety policies and procedures including reporting and recording any health and safety incident or accident
- Adhere to host employers adult and children safeguarding policies and procedures
This job description is not exhaustive, and duties may vary with the requirements of the PCN
Person Specification
Disposition / Attitudes
Essential
- Demonstrable ability to show kindness and compassion
- Demonstrate ability to reflect and learn from situations
- Identifies difficulties as challenges and works with others to identify solutions
- Demonstrates cooperative team working and awareness of the roles of other professionals
- Able to work on own initiative, organising and prioritising own workload to set deadlines
- Ability to adapt and change approach as circumstance dictates
- Persistence and ability to keep going in difficult situations and with complex and uncertain pieces of work
- Understanding of and commitment to equality of opportunity and good working relationships
- An ability to maintain confidentiality and trust
- Can do attitude, able to maintain positivity in the face of adversity
- Good time keeping
- Flexible approach to work
- Ability to work flexibly across days of the week
Qualifications
Essential
- NVQ Level 3 or equivalent level of knowledge in office procedures
Knowledge and Skills
Essential
- Experience of planning and organising complex meetings/agendas
- Evidence of working with EMIS
- Evidence of ability to support collation and analysis of data
- Excellent verbal and written skills
- Ability to provide and receive complex information
- Excellent interpersonal skills
Desirable
- Proven track record of effective use of networking and influencing skills
Experience
Essential
- Experience of working under own direction
- Experience in a patient focused environment
- Evidence of experience in wide range of administrative systems and software programmes
Desirable
- Experience of supporting service improvement
- Previous experience in NHS/Primary Care/Local Authority role
- Experience of venepuncture
Person Specification
Disposition / Attitudes
Essential
- Demonstrable ability to show kindness and compassion
- Demonstrate ability to reflect and learn from situations
- Identifies difficulties as challenges and works with others to identify solutions
- Demonstrates cooperative team working and awareness of the roles of other professionals
- Able to work on own initiative, organising and prioritising own workload to set deadlines
- Ability to adapt and change approach as circumstance dictates
- Persistence and ability to keep going in difficult situations and with complex and uncertain pieces of work
- Understanding of and commitment to equality of opportunity and good working relationships
- An ability to maintain confidentiality and trust
- Can do attitude, able to maintain positivity in the face of adversity
- Good time keeping
- Flexible approach to work
- Ability to work flexibly across days of the week
Qualifications
Essential
- NVQ Level 3 or equivalent level of knowledge in office procedures
Knowledge and Skills
Essential
- Experience of planning and organising complex meetings/agendas
- Evidence of working with EMIS
- Evidence of ability to support collation and analysis of data
- Excellent verbal and written skills
- Ability to provide and receive complex information
- Excellent interpersonal skills
Desirable
- Proven track record of effective use of networking and influencing skills
Experience
Essential
- Experience of working under own direction
- Experience in a patient focused environment
- Evidence of experience in wide range of administrative systems and software programmes
Desirable
- Experience of supporting service improvement
- Previous experience in NHS/Primary Care/Local Authority role
- Experience of venepuncture
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.
