Job summary
Seisdon
Primary Care Network have an opportunity for a Care Co-ordinator to support the
PCN to deliver high quality patient care by supporting their multi-disciplinary
team(MDT). As Care Co-ordinator your key responsibilities will include, but not
be limited to managing the co-ordination of PCN DES requirements.
An area of
focus will be supporting Care Homes and frailty. You will work closely with GPs
and other primary and community care professionals within the PCN to
co-ordinate the care of care home and frailty patients who would benefit from
being reviewed via our MDT. You will act as a point of contact for patients,
families and professionals. You will support the MDT with the weekly virtual
home round through identification of people in need of review. The PCN is very
supportive of any development opportunities. Join a genuinely fantastic PCN
that prioritises staff well-being and patients whilst offering a great
work/life balance. Seisdon
PCN covers Wombourne, Claverly, Perton, Codsall, Bilbrook and Featherstone
areas.
Main duties of the job
The Care
Co-ordinator will
work closely with the relevant teams to help and support the monthly
multi-disciplinary team (MDT) meetings and ongoing patient case management.
This will involve linking with the member GP surgeries, a range of Community
Health Services, Social Services and Care Homes.
Also working closely with agencies
involved in MDT meetings: GP Practice teams, the PCN Additional Roles
workforce, Community Teams, Social Services and the Frailty service Elderly
Care facilitator ensuring that there is consistent representation at meetings.
The Care Co-ordinator will demonstrate
excellent organisational skills, be flexible in their approach, able to
exercise initiative and demonstrate consistently high standards of
professionalism. They must at all times be aware of the need for
confidentiality and integrity. They will also need a basic knowledge of Health
and Social Care terminology and eligibility criteria and current team
structures and pathways.
The Care Co-ordinator will need to
oversee the PCN employed additional roles and co-ordinate training, leave and
absences while working closely with the PCN Clinical Director and Manager.
About us
The 8 GP Practices in Seisdon cover Featherstone, Bilbrook, Codsall, Perton, Wombourne and Claverley.
This role is a new and exciting role within Seisdon PCN network and will expand to support many other areas of care with the requirements from NHS England as part of the Long Term Plan.
Job description
Job responsibilities
Scope and
Purpose of the role
The Care Co-ordinator will be a pivotal
part of the MDT team, by:
- Planning and co-ordinating the MDT
meetings, clinical and social care as agreed with the supervising practitioner
in line with clinical governance and within agreed professional standards and
guidelines.
- Working pro-actively as a member of the
multi-disciplinary team in support of the member practice teams.
- The
Care Co-ordinator will provide support to the Clinical Director and PCN Manager
in overseeing the PCN employed staff.
Clinical Liaison
Responsibilities
- Working closely with the member GP
practices within Seisdon PCN to help ensure wrap around support for patients in
residential or nursing care or the frail elderly in the Community.
- Deliver and effectively communicate
integrated patient centred-care through appropriate working with the wider
primary care multi-disciplinary team and social care networks.
- To act as the first point of contact
for professionals making enquiries to the MDT.
- To provide co-ordination of pro-active
MDT care for care homes and identified frail patients.
- Supporting the PCN Care Home DES for
patients in nursing or care homes and assisting member practices in the deliver
key annual reviews and immunisations. This may require co-ordinating practice,
PCN Additional Roles and Community teams.
- To work with the wider MDT to identify
appropriate high risk patients to ensure that patients are reviewed and
anticipatory care plans are developed in an agreed timeframe.
- To obtain consent from patients
identified by the Frailty pathway to be discussed at the MDT and for onward
referral into the Staying Well Service.
- Where appropriate to be a point of
contact for patient, carers and family members ensuring good communication
between GP services and patients, relatives or carers.
- To be a point of contact for care homes
staff and proactively developing strong communication links with assigned care
homes.
- To provide co-ordination for new
objectives and projects as defined by NHS England as required
Administrative
Responsibilities
- To
work as a key member of the MDT to help support the development of effective
MDT meetings, preparing agendas, minutes and communicating attendee
information.
- To
ensure that action points identified within the MDT are recorded and followed
up
- Under
guidance from the practice managers, take initiative in the organisation and
administration of MDT working to minimise the demands upon the
multidisciplinary team.
- To
cross reference the patients identified by the MDT team, supporting the
development of personalised care and support plans, as well as ensuring reviews
are carried out within agreed timeframes.
- Ensure
that patients Anticipatory Care Plans, relevant results and associated
correspondence are available to the MDT, liaising with all agencies as
appropriate, accessing IT systems to ensure relevant information is available.
- Inputting
into the patient electronic records in line with professional and
organisational requirements where necessary.
- To be a
point of contact for the ARRS workforce updating training, leave and absences
while working closely with the PCN Clinical Director and Manager.
- Expectation
to undertake and participate in training as required.
Health
and Safety and Risk Management
- To comply with the Health and Safety at
Work Act 1974 and PCN Health and Safety policies in particular following agreed
safe working procedures.
- To comply with the Data Protection Act (2018) and
the Access to Health Records Act (1990) and data sharing agreements.
Equality and Diversity
To
carry out responsibilities in line with Equal Opportunities policies and
procedures.
Confidentiality
To
maintain confidentiality of information relating to patients, staff and other
users of the service in accordance with the Data Protection Act and Caldicott
Guardian guidance.
Communication
and Working Arrangements
The
post-holder will establish and maintain effective communication pathways with
the following:
- Clinicians
and managers in the PCN practices
- Nurses
and managers in the aligned care homes
- Relatives
of patients where applicable
- Clinicians
and administrators in the Community Teams
- The
PCN Additional Roles team.
Special
Working Conditions
- To
undertake duties at the PCN member practices as required.
- Undertake
tasks consistent with the level and scope of the post and ensuring work is
delivered in a timely and effective manner.
- Indirect
exposure to emotional circumstances (details at MDT meetings and processing
details of terminally ill patients)
- During
the Covid pandemic MDT meetings have been conducted virtually. Some meetings
may revert back to meeting at practices sites in the future.
Rehabilitation
of Offenders Act 1994
Because
of the nature of the work, this post is exempt from the provisions of Section
4(2) of the Rehabilitation of Offenders Act 1994 (Exceptions) Order 1995. Applicants for posts are not entitled to
withhold information about convictions which for other purposes are spent
under the provisions of the Act and in the event of employment any failure to
disclose such convictions could result in disciplinary action or dismissal by
the Practice. Any information given will
be completely confidential and will be considered only in relation to an
applicant of a position to which the order applies.
Job
Description Agreement
This
job description is intended to provide an outline of the key tasks and
responsibilities only. There may be
other duties required of the post-holder commensurate with the position. This description will be open to regular
review and may be amended to take into account development within the PCN and
National Directives. All members of
staff should be prepared to take on additional duties or relinquish existing
duties in order to maintain the efficient running of the practices and MDT
meetings.
Job description
Job responsibilities
Scope and
Purpose of the role
The Care Co-ordinator will be a pivotal
part of the MDT team, by:
- Planning and co-ordinating the MDT
meetings, clinical and social care as agreed with the supervising practitioner
in line with clinical governance and within agreed professional standards and
guidelines.
- Working pro-actively as a member of the
multi-disciplinary team in support of the member practice teams.
- The
Care Co-ordinator will provide support to the Clinical Director and PCN Manager
in overseeing the PCN employed staff.
Clinical Liaison
Responsibilities
- Working closely with the member GP
practices within Seisdon PCN to help ensure wrap around support for patients in
residential or nursing care or the frail elderly in the Community.
- Deliver and effectively communicate
integrated patient centred-care through appropriate working with the wider
primary care multi-disciplinary team and social care networks.
- To act as the first point of contact
for professionals making enquiries to the MDT.
- To provide co-ordination of pro-active
MDT care for care homes and identified frail patients.
- Supporting the PCN Care Home DES for
patients in nursing or care homes and assisting member practices in the deliver
key annual reviews and immunisations. This may require co-ordinating practice,
PCN Additional Roles and Community teams.
- To work with the wider MDT to identify
appropriate high risk patients to ensure that patients are reviewed and
anticipatory care plans are developed in an agreed timeframe.
- To obtain consent from patients
identified by the Frailty pathway to be discussed at the MDT and for onward
referral into the Staying Well Service.
- Where appropriate to be a point of
contact for patient, carers and family members ensuring good communication
between GP services and patients, relatives or carers.
- To be a point of contact for care homes
staff and proactively developing strong communication links with assigned care
homes.
- To provide co-ordination for new
objectives and projects as defined by NHS England as required
Administrative
Responsibilities
- To
work as a key member of the MDT to help support the development of effective
MDT meetings, preparing agendas, minutes and communicating attendee
information.
- To
ensure that action points identified within the MDT are recorded and followed
up
- Under
guidance from the practice managers, take initiative in the organisation and
administration of MDT working to minimise the demands upon the
multidisciplinary team.
- To
cross reference the patients identified by the MDT team, supporting the
development of personalised care and support plans, as well as ensuring reviews
are carried out within agreed timeframes.
- Ensure
that patients Anticipatory Care Plans, relevant results and associated
correspondence are available to the MDT, liaising with all agencies as
appropriate, accessing IT systems to ensure relevant information is available.
- Inputting
into the patient electronic records in line with professional and
organisational requirements where necessary.
- To be a
point of contact for the ARRS workforce updating training, leave and absences
while working closely with the PCN Clinical Director and Manager.
- Expectation
to undertake and participate in training as required.
Health
and Safety and Risk Management
- To comply with the Health and Safety at
Work Act 1974 and PCN Health and Safety policies in particular following agreed
safe working procedures.
- To comply with the Data Protection Act (2018) and
the Access to Health Records Act (1990) and data sharing agreements.
Equality and Diversity
To
carry out responsibilities in line with Equal Opportunities policies and
procedures.
Confidentiality
To
maintain confidentiality of information relating to patients, staff and other
users of the service in accordance with the Data Protection Act and Caldicott
Guardian guidance.
Communication
and Working Arrangements
The
post-holder will establish and maintain effective communication pathways with
the following:
- Clinicians
and managers in the PCN practices
- Nurses
and managers in the aligned care homes
- Relatives
of patients where applicable
- Clinicians
and administrators in the Community Teams
- The
PCN Additional Roles team.
Special
Working Conditions
- To
undertake duties at the PCN member practices as required.
- Undertake
tasks consistent with the level and scope of the post and ensuring work is
delivered in a timely and effective manner.
- Indirect
exposure to emotional circumstances (details at MDT meetings and processing
details of terminally ill patients)
- During
the Covid pandemic MDT meetings have been conducted virtually. Some meetings
may revert back to meeting at practices sites in the future.
Rehabilitation
of Offenders Act 1994
Because
of the nature of the work, this post is exempt from the provisions of Section
4(2) of the Rehabilitation of Offenders Act 1994 (Exceptions) Order 1995. Applicants for posts are not entitled to
withhold information about convictions which for other purposes are spent
under the provisions of the Act and in the event of employment any failure to
disclose such convictions could result in disciplinary action or dismissal by
the Practice. Any information given will
be completely confidential and will be considered only in relation to an
applicant of a position to which the order applies.
Job
Description Agreement
This
job description is intended to provide an outline of the key tasks and
responsibilities only. There may be
other duties required of the post-holder commensurate with the position. This description will be open to regular
review and may be amended to take into account development within the PCN and
National Directives. All members of
staff should be prepared to take on additional duties or relinquish existing
duties in order to maintain the efficient running of the practices and MDT
meetings.
Person Specification
Personal Qualities
Essential
- Ability 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
- Commitment to reducing health inequalities and proactively working to reach people from all communities
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
- Ability 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 the person needs are beyond the scope of the Care Coordinator role e.g. when there is a mental health need requiring a qualified practitioner
- Able to advise and assist with personal health budgets, personalised care and support plans
- Able to finish work tasks
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- Commitment 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
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- High level of written and oral communication skills
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Understanding of the needs of patients with LD and/or mental health issues and ability to support these groups
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
Qualifications
Essential
- GCSE pass in English and Maths (Grade 4, C or above)
Desirable
- NVQ Level 3 or equivalent level of knowledge in office procedures
Other
Essential
- Friendly and approachable.
- Good presentation of self, enthusiastic, flexible, innovative.
- Flexible attitude to working arrangements. Must be able to work within changing environments
- Adaptable, friendly, polite, courteous and caring.
- Motivated and committed on an individual basis and when working within a team.
- Receptive to feedback and the willingness to learn and develop.
- Ability to travel between sites
Skills & Knowledge
Essential
- Ability to work as part of a team.
- Ability to prioritise and manage own workload.
- Ability to use initiative and take action accordingly.
- Experience of planning and organising complex meetings/agendas
- Evidence of ability to support collation and analysis of data
- Excellent verbal and written skills
- Demonstrable ability to show kindness and compassion
- Excellent interpersonal skills
- Proven track record of effective use of networking and influencing skills
- Evidence of working with IT systems
- Ability understand, develop and receive complex information
- Able to understand medical terminology.
Desirable
- Experience in use of a medical software package such as EMIS.
- Experience of using databases and excel
- Ability to use Microsoft Office packages, including Microsoft teams
- Knowledge of working in a MDT healthcare system.
Experience
Essential
- Experience of working under own direction
- Evidence of experience in a range of administrative systems and software programme
Desirable
- Experience of supporting service improvement
- Previous experience in NHS/Primary Care role
Person Specification
Personal Qualities
Essential
- Ability 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
- Commitment to reducing health inequalities and proactively working to reach people from all communities
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
- Ability 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 the person needs are beyond the scope of the Care Coordinator role e.g. when there is a mental health need requiring a qualified practitioner
- Able to advise and assist with personal health budgets, personalised care and support plans
- Able to finish work tasks
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- Commitment 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
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- High level of written and oral communication skills
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Understanding of the needs of patients with LD and/or mental health issues and ability to support these groups
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
Qualifications
Essential
- GCSE pass in English and Maths (Grade 4, C or above)
Desirable
- NVQ Level 3 or equivalent level of knowledge in office procedures
Other
Essential
- Friendly and approachable.
- Good presentation of self, enthusiastic, flexible, innovative.
- Flexible attitude to working arrangements. Must be able to work within changing environments
- Adaptable, friendly, polite, courteous and caring.
- Motivated and committed on an individual basis and when working within a team.
- Receptive to feedback and the willingness to learn and develop.
- Ability to travel between sites
Skills & Knowledge
Essential
- Ability to work as part of a team.
- Ability to prioritise and manage own workload.
- Ability to use initiative and take action accordingly.
- Experience of planning and organising complex meetings/agendas
- Evidence of ability to support collation and analysis of data
- Excellent verbal and written skills
- Demonstrable ability to show kindness and compassion
- Excellent interpersonal skills
- Proven track record of effective use of networking and influencing skills
- Evidence of working with IT systems
- Ability understand, develop and receive complex information
- Able to understand medical terminology.
Desirable
- Experience in use of a medical software package such as EMIS.
- Experience of using databases and excel
- Ability to use Microsoft Office packages, including Microsoft teams
- Knowledge of working in a MDT healthcare system.
Experience
Essential
- Experience of working under own direction
- Evidence of experience in a range of administrative systems and software programme
Desirable
- Experience of supporting service improvement
- Previous experience in NHS/Primary Care role
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.
