Job summary
This role is to
support the smooth co-ordination of patient care across the Crawley Care
Collaborative Primary Care Network for the benefit of our patients. The post
holder will join a team of PCN Care Coordinators.
The post holder will work at one of the
network practices, Langley Corner Surgery.
Part time - 20 hours per week.
Permanent position.
Main duties of the job
The Care Coordinator will be responsible for consulting with patients and determining their needs, developing care plans, coordinating patient-care services, educating them about their condition, empowering them to be independent whenever possible and working with the care team to evaluate interventions.
This role will be expected to heavily support the practice to reach its targets for their Enhanced Services and Quality Outcome Framework (QOF).This role will need to support (where necessary) all additional projects led by NHSE or CCG which will support the need and care of the practices patient list.
About us
Alliance for Better Care CIC is a GP Federation
that unites 47 NHS GP practices across 12 Primary Care Networks in Sussex and
Surrey. We support our Primary Care colleagues as well as their patients, to
transform how healthcare is managed within the community.
As a membership organisation, our focus is to work in partnership with our
members and help them to improve the provision of General Practices in the
local area.
We work with and listen to our GP Practices, PCNs, Hospitals, Community
Organisations and the Third Sector. These vital partnerships ensure that,
together, we deliver a truly integrated approach that offers the support and
expertise needed to effectively serve our communities.
Job description
Job responsibilities
Key
Responsibilities and Duties
- To
support adult patients and assist them through the healthcare system by acting
as a patient advocate and navigator, empowering them and educating them to
promote and support their independence.
- To talk
to patients, and where appropriate their families and/or carers, on the
practice premises, remotely by telephone or video, or in the patients home if
needed.
- Support the practice to reach its
targets for their Enhanced Services and Quality Outcome Framework (QOF).
MDT Coordination
- Overall
responsibility for arranging MDT meetings and the smooth running of integrated
care within the medical centre. A key role of the Care Coordinator will be to
schedule the MDT meetings and manage the meeting agenda items, ensuring that
all new referrals are identified, and information is circulated to team members
in advance of the meeting.
- Identify
patients to discuss at PCN level MDTs with a view to reducing unplanned
admissions and exacerbation of conditions.
Managing a caseload
- Identify
patients that may need support by receiving information about transfers of care
(including hospital admissions and discharges) and from internal practice
intelligence.
- Educate patients (and if applicable and if appropriate consent is in
place, their carers or family) about their condition and medication and give
them specific instructions.
- Educate patients (and if applicable and if appropriate consent is in
place, their carers or family) about their condition and medication and give
them specific instructions.
- Educate patients (and if applicable and if appropriate consent is in
place, their carers or family) about their condition and medication and give
them specific instructions.
- Help patients
understand their condition by liaising with clinical colleagues, especially the
practice pharmacists, regarding their medication. Aim for patients to have
specific instructions regarding their medication and understand how they access
repeat prescriptions and reviews.
- With the help
of relevant clinical colleagues, develop a care plan to address patients
personal health care needs. Ensure care plans are maintained, updated, and
uploaded to all relevant systems for sharing with other providers, including
SystmOne and ShareMyCare.
- Promote
clear communication amongst a care team and treating clinicians by ensuring
awareness regarding patient care plans.
- Assist and empower the patient to consult and
collaborate with other health care providers and specialists to set up patient
appointments and treatment plans.
- Check in on the patient regularly and evaluate and document their
progress.
Linking with other services
- Signpost team members, service users and carers to relevant services
including the PCN Social Prescribing Link Worker Service.
- Liaise
with the Social Prescriber regarding patients that are identified as needing
well-being support.
- Liaise
with PCN clinicians responsible for frailty regarding patients that are
identified as needing ongoing support.
- Liaise
with acute trusts, hospices, community and social care providers as required.
Record
Keeping
- Keep accurate and up-to-date records of
contact with patients, carers and professionals, including use of SystmOne to
record patient contact on the medical record.
- Use accurate SNOMED codes to record
patient contacts and interventions, mainly via the use of provided templates,
for audit purposes and monitoring and measuring outcomes
- Manage reporting
required and associated within the DES specifications for required services.
- Report case studies and outcomes to the
PCN on a quarterly basis.
General
Responsibilities- Work as part of the team to seek
feedback, continually improve the service and
contribute to business planning
- Undertake any tasks
consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and
effective manner.
- Attend ongoing
training and courses to keep abreast of new developments in health care
- Treat patients with empathy and respect
and conduct oneself in a professional manner.
- Attend and contribute to relevant
meetings.
- Duties may vary from time to time,
without changing the general character of the post or the level of
responsibility.
Please see full Job Description for further information.
Job description
Job responsibilities
Key
Responsibilities and Duties
- To
support adult patients and assist them through the healthcare system by acting
as a patient advocate and navigator, empowering them and educating them to
promote and support their independence.
- To talk
to patients, and where appropriate their families and/or carers, on the
practice premises, remotely by telephone or video, or in the patients home if
needed.
- Support the practice to reach its
targets for their Enhanced Services and Quality Outcome Framework (QOF).
MDT Coordination
- Overall
responsibility for arranging MDT meetings and the smooth running of integrated
care within the medical centre. A key role of the Care Coordinator will be to
schedule the MDT meetings and manage the meeting agenda items, ensuring that
all new referrals are identified, and information is circulated to team members
in advance of the meeting.
- Identify
patients to discuss at PCN level MDTs with a view to reducing unplanned
admissions and exacerbation of conditions.
Managing a caseload
- Identify
patients that may need support by receiving information about transfers of care
(including hospital admissions and discharges) and from internal practice
intelligence.
- Educate patients (and if applicable and if appropriate consent is in
place, their carers or family) about their condition and medication and give
them specific instructions.
- Educate patients (and if applicable and if appropriate consent is in
place, their carers or family) about their condition and medication and give
them specific instructions.
- Educate patients (and if applicable and if appropriate consent is in
place, their carers or family) about their condition and medication and give
them specific instructions.
- Help patients
understand their condition by liaising with clinical colleagues, especially the
practice pharmacists, regarding their medication. Aim for patients to have
specific instructions regarding their medication and understand how they access
repeat prescriptions and reviews.
- With the help
of relevant clinical colleagues, develop a care plan to address patients
personal health care needs. Ensure care plans are maintained, updated, and
uploaded to all relevant systems for sharing with other providers, including
SystmOne and ShareMyCare.
- Promote
clear communication amongst a care team and treating clinicians by ensuring
awareness regarding patient care plans.
- Assist and empower the patient to consult and
collaborate with other health care providers and specialists to set up patient
appointments and treatment plans.
- Check in on the patient regularly and evaluate and document their
progress.
Linking with other services
- Signpost team members, service users and carers to relevant services
including the PCN Social Prescribing Link Worker Service.
- Liaise
with the Social Prescriber regarding patients that are identified as needing
well-being support.
- Liaise
with PCN clinicians responsible for frailty regarding patients that are
identified as needing ongoing support.
- Liaise
with acute trusts, hospices, community and social care providers as required.
Record
Keeping
- Keep accurate and up-to-date records of
contact with patients, carers and professionals, including use of SystmOne to
record patient contact on the medical record.
- Use accurate SNOMED codes to record
patient contacts and interventions, mainly via the use of provided templates,
for audit purposes and monitoring and measuring outcomes
- Manage reporting
required and associated within the DES specifications for required services.
- Report case studies and outcomes to the
PCN on a quarterly basis.
General
Responsibilities- Work as part of the team to seek
feedback, continually improve the service and
contribute to business planning
- Undertake any tasks
consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and
effective manner.
- Attend ongoing
training and courses to keep abreast of new developments in health care
- Treat patients with empathy and respect
and conduct oneself in a professional manner.
- Attend and contribute to relevant
meetings.
- Duties may vary from time to time,
without changing the general character of the post or the level of
responsibility.
Please see full Job Description for further information.
Person Specification
Qualifications
Essential
- Demonstrable commitment to professional and personal development.
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards.
- Training in motivational coaching and interviewing or equivalent experience.
Experience
Desirable
- Experience of working directly in either the NHS or Adult Social Care.
Personal Qualities & Attributes
Essential
- Able to listen, empathise with people and provide person- centred support in a non-judgemental way.
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Committed to reducing health inequalities and proactively working to reach people from all communities.
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Able to identify risk and assess/manage risk when working with individuals.
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.
- Able to provide leadership and to finish work tasks.
- Able to maintain effective working relationships and to promote collaborative practice with all colleagues.
- Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues.
- Demonstrates personal accountability, emotional resilience and works well under pressure.
- Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
- High level of written and oral communication skills.
- Able to work flexibly and enthusiastically within a team or on own initiative.
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
Desirable
- Excellent IT skills including Excel and knowledge of GP clinical systems.
Person Specification
Qualifications
Essential
- Demonstrable commitment to professional and personal development.
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards.
- Training in motivational coaching and interviewing or equivalent experience.
Experience
Desirable
- Experience of working directly in either the NHS or Adult Social Care.
Personal Qualities & Attributes
Essential
- Able to listen, empathise with people and provide person- centred support in a non-judgemental way.
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Committed to reducing health inequalities and proactively working to reach people from all communities.
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Able to identify risk and assess/manage risk when working with individuals.
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.
- Able to provide leadership and to finish work tasks.
- Able to maintain effective working relationships and to promote collaborative practice with all colleagues.
- Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues.
- Demonstrates personal accountability, emotional resilience and works well under pressure.
- Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
- High level of written and oral communication skills.
- Able to work flexibly and enthusiastically within a team or on own initiative.
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
Desirable
- Excellent IT skills including Excel and knowledge of GP clinical systems.
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.
