Job summary
We have a fantastic opportunity to join our innovative team of Care Co-ordinators working in the Stockport East and South (SES) Primary Care Network (PCN) in Stockport as a Vulnerable Patient Care Coordinator.
There are two positions available, and the role will involve working with vulnerable patients, for example those on safeguarding registers, those who are frail, have dementia or learning disabilities.
You will be working with the patients, their families, carers and other healthcare and social care professionals involved in their care to support their needs. This will involve seeing this cohort of patients either within their own homes or within the GP practices depending on patient need.
You will support all key activity across the PCN; supporting the PCN Manager and associated practices by co-ordinating activity and providing an efficient, well organised administrative and operational support to the clinicians and managers in the network to ensure effective timely delivery of the PCN objectives.
We are accepting CVs for this role, please also include a cover letter outlining your suitabilty for the role. Please note that the use of AI is monitored during the shortlisting process; if you have used this please declare this in your statement explaining what type of AI tools have been used and for what purpose.
Main duties of the job
Care
Co-ordinator roles are new to Primary Care and we are looking to recruit two Vulnerable Patients Care Co-ordinators to work across the Stockport borough.
This role aims to improve health outcomes, promote timely care, and reduce health inequalities through effective care planning, system navigation, and communication between patients, carers, and the healthcare team. As a Care Co-ordinator, you will be integral in overseeing the interdisciplinary care of your patients and will be
responsible for co-ordinating a package of care and support from a variety of
specialists.
About us
Viaduct Care CIC is the company structure for Stockport's GP Federation and represents all of its local GP Practices. Covering a patient population of circa 300,000 practices are split into 6 PCNs with each serving a population of around 30,000-50,000 patients.
Viaduct Care represents the collective voice and interests of its member practices and as a key stakeholder in Stockport Together aims to influence and support the design and delivery of major service and system changes by being a strong and effective partner with other major service providers.
One of our priorities at Viaduct Care is to ensure that wellbeing and development of our team is at the forefront of everything we do. We have recently launched our new employee assistance programme, assisting our team to get access to a range of advice 24 hours a day. Additionally, we are keen to provide opportunities for team members to develop and grow including access to an extensive range of training and up to five paid study days per year.
Click on the Why Join Viaduct Care link to the right to find out about all of our staff support and benefits.
Job description
Job responsibilities
- To work as a team of Care Coordinators, with the GPs and other primary care professionals within the PCN to proactively identify and support some of our most vulnerable patients who require additional input due to their presentation. The focus being those patients with moderate to severe frailty, those with a diagnosis of dementia or cognitive impairment, and those returning home after a recent admission to hospital, with the aim of delivering proactive and reactive care to this group of patients. In addition to this, the role may include patients with learning disabilities, those on the safeguarding register, those with diagnosis of cancer and to support with cancer screening uptake as well.
- Be flexible to work collaboratively and support the other care coordinator teams across the PCN with work that is required as directed by the PCN management team.
- Be responsible for running weekly EMIS searches to identify those moderately and severely frail patients, those with recent admissions to hospital or ED attendances, particularly those attending with falls and those with known dementia, contacting patients to arrange appointments, whether in their own homes or bringing them into clinic.
- To visit these patients in their own homes or see them within the practice where appropriate to complete a holistic review of the patients health and social needs following an agreed assessment pathway.
- Data collection and submission, filing, general admin etc.
- Bring together all a persons identified care and support needs and what matters to them; explore the options to address these in a single personalised care and support plan created in collaboration with the patient and their family as appropriate.
- To support with venepuncture and NHS Health Checks (pulse measurement, blood pressure monitoring, height and weight measurement and waist measurement) where required.
- Communicating at least monthly with the PCN management team about ongoing workstreams and work completed.
- Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing; explore and assist people to access personal health budgets where appropriate.
- Support the coordination and delivery of multidisciplinary teams within PCN, in particular working with the PCN Pharmacy team.
- Provide coordination and navigation for individuals and their carers across health and care services, working closely with social prescribing link workers and other primary care roles such as the Advanced Community Practitioners/District nurses.
- To help patients to manage their needs through answering queries, making, and managing appointments.
- Assist and coordinate practices in meeting PCN DES, Locally Commissioned Service Targets and Impact and Investment Fund (IIF) targets, and practice Quality Outcomes Framework (QoF) targets.
- Responsible for coordinating any joint projects, e.g. vaccination and any associated administration.
It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role.
This list of duties is not intended to be exhaustive, but indicates the main areas of work and may be subject to change after consultation with the post-holder and the wider team to meet the changing needs of the service.
Job description
Job responsibilities
- To work as a team of Care Coordinators, with the GPs and other primary care professionals within the PCN to proactively identify and support some of our most vulnerable patients who require additional input due to their presentation. The focus being those patients with moderate to severe frailty, those with a diagnosis of dementia or cognitive impairment, and those returning home after a recent admission to hospital, with the aim of delivering proactive and reactive care to this group of patients. In addition to this, the role may include patients with learning disabilities, those on the safeguarding register, those with diagnosis of cancer and to support with cancer screening uptake as well.
- Be flexible to work collaboratively and support the other care coordinator teams across the PCN with work that is required as directed by the PCN management team.
- Be responsible for running weekly EMIS searches to identify those moderately and severely frail patients, those with recent admissions to hospital or ED attendances, particularly those attending with falls and those with known dementia, contacting patients to arrange appointments, whether in their own homes or bringing them into clinic.
- To visit these patients in their own homes or see them within the practice where appropriate to complete a holistic review of the patients health and social needs following an agreed assessment pathway.
- Data collection and submission, filing, general admin etc.
- Bring together all a persons identified care and support needs and what matters to them; explore the options to address these in a single personalised care and support plan created in collaboration with the patient and their family as appropriate.
- To support with venepuncture and NHS Health Checks (pulse measurement, blood pressure monitoring, height and weight measurement and waist measurement) where required.
- Communicating at least monthly with the PCN management team about ongoing workstreams and work completed.
- Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing; explore and assist people to access personal health budgets where appropriate.
- Support the coordination and delivery of multidisciplinary teams within PCN, in particular working with the PCN Pharmacy team.
- Provide coordination and navigation for individuals and their carers across health and care services, working closely with social prescribing link workers and other primary care roles such as the Advanced Community Practitioners/District nurses.
- To help patients to manage their needs through answering queries, making, and managing appointments.
- Assist and coordinate practices in meeting PCN DES, Locally Commissioned Service Targets and Impact and Investment Fund (IIF) targets, and practice Quality Outcomes Framework (QoF) targets.
- Responsible for coordinating any joint projects, e.g. vaccination and any associated administration.
It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role.
This list of duties is not intended to be exhaustive, but indicates the main areas of work and may be subject to change after consultation with the post-holder and the wider team to meet the changing needs of the service.
Person Specification
Experience
Essential
- Experience of working both autonomously and as part of a multidisciplinary team in a health, social care or community setting.
- Experience in communicating effectively with a wide range of people, including patients, carers, and health and social care professionals.
- Experience of managing a varied and busy workload, prioritising tasks, and working to deadlines without direct supervision.
Desirable
- Experience of working with older adults, including those with dementia, frailty or at risk of falls.
- Experience in using care planning templates (e.g. Ardens) and digital systems.
- Evidence of working within a multidisciplinary team.
Knowledge and Skills
Essential
- Knowledge around importance of confidentiality and data protection.
- Knowledge and understanding of Adult Social Care frameworks, policies, and local service provision.
- Understanding of dementia, frailty syndromes and falls risk in older adults.
- Ability to recognise and respond appropriately to risk and safeguarding concerns.
- Ability to carry out comprehensive assessments including: dementia reviews, frailty assessments and falls risk assessments.
- Ability to plan and prioritise workload independently.
- Ability to maintain accurate and concise records.
- Ability to provide information effectively.
- Good communication and interpersonal skills, including an ability to carry out DNAR and future planning discussions sensitively and appropriately.
- Good IT skills and proficient in the use of various Microsoft packages.
- Ability to work flexibly in an innovative and developing role.
Desirable
- Ability to undertake and interpret relevant clinical observations and tests (e.g., BP, MUST score, bloods) or willing to learn.
- Understanding of polypharmacy and medication reviews (liaising with SIPS/clinical pharmacist team).
Additional Attributes
Essential
- Committed to improving outcomes for vulnerable patients.
- Be able to offer support in a person centred and non-judgmental way.
- Willingness to work and travel in settings across Stockport and ability to work from home if required.
- Have a full, clean driving license and have access to a car during all contractual hours.
- Commitment to working towards Viaduct Care CIC's values and ethos as an organisation.
Qualifications
Essential
- Achieved grade C or above, in English and Maths GCSE or equivalent
- PCI Accredited Care Coordinator training (or be willing to work towards this).
Desirable
- NVQ Level III (Health and Social Care) or equivalent or equivalent experience.
- Formal training in working with long term conditions.
- Formal training in venepuncture (or be willing to work towards this).
Person Specification
Experience
Essential
- Experience of working both autonomously and as part of a multidisciplinary team in a health, social care or community setting.
- Experience in communicating effectively with a wide range of people, including patients, carers, and health and social care professionals.
- Experience of managing a varied and busy workload, prioritising tasks, and working to deadlines without direct supervision.
Desirable
- Experience of working with older adults, including those with dementia, frailty or at risk of falls.
- Experience in using care planning templates (e.g. Ardens) and digital systems.
- Evidence of working within a multidisciplinary team.
Knowledge and Skills
Essential
- Knowledge around importance of confidentiality and data protection.
- Knowledge and understanding of Adult Social Care frameworks, policies, and local service provision.
- Understanding of dementia, frailty syndromes and falls risk in older adults.
- Ability to recognise and respond appropriately to risk and safeguarding concerns.
- Ability to carry out comprehensive assessments including: dementia reviews, frailty assessments and falls risk assessments.
- Ability to plan and prioritise workload independently.
- Ability to maintain accurate and concise records.
- Ability to provide information effectively.
- Good communication and interpersonal skills, including an ability to carry out DNAR and future planning discussions sensitively and appropriately.
- Good IT skills and proficient in the use of various Microsoft packages.
- Ability to work flexibly in an innovative and developing role.
Desirable
- Ability to undertake and interpret relevant clinical observations and tests (e.g., BP, MUST score, bloods) or willing to learn.
- Understanding of polypharmacy and medication reviews (liaising with SIPS/clinical pharmacist team).
Additional Attributes
Essential
- Committed to improving outcomes for vulnerable patients.
- Be able to offer support in a person centred and non-judgmental way.
- Willingness to work and travel in settings across Stockport and ability to work from home if required.
- Have a full, clean driving license and have access to a car during all contractual hours.
- Commitment to working towards Viaduct Care CIC's values and ethos as an organisation.
Qualifications
Essential
- Achieved grade C or above, in English and Maths GCSE or equivalent
- PCI Accredited Care Coordinator training (or be willing to work towards this).
Desirable
- NVQ Level III (Health and Social Care) or equivalent or equivalent experience.
- Formal training in working with long term conditions.
- Formal training in venepuncture (or be willing to work towards this).
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.
