Job summary
MIAA is advertising the above role on behalf of Congleton and Holmes Chapel (CHOC) Primary Care Network, who are seeking to recruit a Care Coordinator to join their Personalised Care Team.
Main duties of the job
This is an opportunity to join the PCN as a Care Co-ordinator, and be part of supporting 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 you will work closely with GPs and other primary and community care professionals within the PCN to co-ordinate the care of care home 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 brilliant work/life balance.
About us
Congleton and Holmes Chapel (CHOC) Primary Care Network (PCN) are made up of four GP Practices which are based in Congleton and Holmes Chapel. We together as a PCN have a patient list size of approximately 48,000, for whom we provide General Practice services. By working together with our local providers of care we are improving the patient experiences of primary care. We are in the Cheshire East Council geographic area.
Our vision at Congleton and Holmes Chapel (CHOC) Primary Care Network (PCN), is to support the NHS long term and plan protecting the long term- sustainability of the general practice model. We aim to bring together collaborative working for health, social care and the voluntary sector improving systems and processes enabling increased time to deliver improved patient care. We will achieve more by harnessing the strengths of our stakeholders. Our mission is to place the patient at the heart of everything we do within the community delivered by a multi-disciplinary team improving our patients health.
The successful candidate will join a growing PCN Team, (including Clinical Pharmacists, Paramedic Practitioners, FCPs, PA, SPLWs and MHPs) and will be supported by the PCN Leadership Team and the PCN Advanced Practitioner Clinical Pharmacist. Regular development sessions, clinical supervision, teaching, training and opportunities to upskill will be provided, linking in with the PCN Clinical Educational Lead.
Job description
Job responsibilities
The Care Coordinator will have a broad portfolio of duties that originate from the requirements of the
PCN DES and will contribute to better patient care.
This will be achieved by coordinating the work of our healthcare professionals and non-clinical staff
involved in the care of patients. The post holder will work closely with practice staff who support the
wider patient call and recall, to offer where possible, a one-contact approach to meeting the patients
needs.
The successful candidates will work in Practice, with external agencies and across our PCN Practices and
will be an essential part of a dynamic and forward-thinking Multi-Disciplinary Team (MDT) who are
providing support and enhanced care to groups of patients, including vulnerable patients and patients
in the care home setting.
The Care Coordinator (Data) will undertake work in line with PCN and Practice directed priorities. Thefollowing are the core responsibilities of the Care Coordinator role:
Enhanced Care in Care Homes
- Manage the Care Home proxy access administration process.
- Support the GP team to identify gaps in existing Care Plans and help produce and annual Personalised Care and Support Plan (PCSP), referring to the patients named GP to complete.
- Liaise with Prospect House Care home to schedule the monthly Clinical Pharmacists visits.
- Liaise with Prospect House Care Home to ensure new admissions and patients who have beendischarged from hospital, are reviewed at the next Ward Round, and have an updated PCSP.
- Coordinate the annual influenza prophylaxis preparation.
- Be the Practice point of contact for Care Home residents relatives and Carers, and ProspectHouse staff.
Clinical Pharmacy Support
- Use EMIS web, risk stratification tools and Ardens Manger to identify and call/recall patients for the Clinical Pharmacy team to review. This includes, but is not limited to, patients for: structuremedication reviews, QOF QI, QOF Medicines Indicators, IIF indicators, Prescribing audits.
Early Cancer Diagnosis
- Support the delivery of PCN objectives under the Early Cancer Diagnosis requirements of thePCN DES. This includes but is not limited to: attending relevant forum meetings, patient follow up from cancer screening, cancer care planning, patient communications.
Cardiovascular Disease Prevention and Diagnosis
- Support patient call and recall is directed by the Practices Quality and Compliance.
Health Inequalities
- Identify patient cohorts being targeted by the PCN / Practices, inviting them to participate inagreed interventions.
- Learning Disabilities care planning.
MDT Meetings
- Prepare the agenda for MDT meetings and contact all parties to ensure attendance and toconfirm patients to be discussed.
- Minute the MDT meetings, add notes and SNOMED codes to the patients Medical Records.
- Disseminate actions and follow-up ahead of the next meeting to ensure actions are completed.
Care Planning
- Support the Practice objectives (local and PCN-level) to ensure Care Plans are actively createdand updated. This includes for Learning Disability patients, Dementia patients, Care Homeresidents and Cancer patients.
- Identify patients without recent care plans in place and work with their name GP to updatethese plans.
- Ensure that preventative actions are agreed and detailed in Care Plans to support thereduction of unnecessary hospital admissions.
Investment and Impact Fund
- Support patient call and recall is directed by the Operations Manager Quality andCompliance.
- Ensure the minimum number of patient contacts by aligning multiple tests and reviews.
Support Data Collection:
- Effective use of the EMIS diary date to effectively manage care.
- Ensure timely and accurate collation of data for the practice and PCN.
- Maintain accurate and up to date records of patient contacts using GP record systems andother IM&T systems relevant to the role i.e. entering notes onto EMIS using agreed SNOMEDcodes.
- Appropriate management of collected data, ensuring all data is kept and shared in accordancewith all relevant governance requirements.
- Validate and quality assure incoming data.
- Run regular patient searches using EMIS in order to have an up-to-date record of progress ofachievement of Key Performance Indicators.
- Case finding to support target achievement and enhancing register prevalence.
Job description
Job responsibilities
The Care Coordinator will have a broad portfolio of duties that originate from the requirements of the
PCN DES and will contribute to better patient care.
This will be achieved by coordinating the work of our healthcare professionals and non-clinical staff
involved in the care of patients. The post holder will work closely with practice staff who support the
wider patient call and recall, to offer where possible, a one-contact approach to meeting the patients
needs.
The successful candidates will work in Practice, with external agencies and across our PCN Practices and
will be an essential part of a dynamic and forward-thinking Multi-Disciplinary Team (MDT) who are
providing support and enhanced care to groups of patients, including vulnerable patients and patients
in the care home setting.
The Care Coordinator (Data) will undertake work in line with PCN and Practice directed priorities. Thefollowing are the core responsibilities of the Care Coordinator role:
Enhanced Care in Care Homes
- Manage the Care Home proxy access administration process.
- Support the GP team to identify gaps in existing Care Plans and help produce and annual Personalised Care and Support Plan (PCSP), referring to the patients named GP to complete.
- Liaise with Prospect House Care home to schedule the monthly Clinical Pharmacists visits.
- Liaise with Prospect House Care Home to ensure new admissions and patients who have beendischarged from hospital, are reviewed at the next Ward Round, and have an updated PCSP.
- Coordinate the annual influenza prophylaxis preparation.
- Be the Practice point of contact for Care Home residents relatives and Carers, and ProspectHouse staff.
Clinical Pharmacy Support
- Use EMIS web, risk stratification tools and Ardens Manger to identify and call/recall patients for the Clinical Pharmacy team to review. This includes, but is not limited to, patients for: structuremedication reviews, QOF QI, QOF Medicines Indicators, IIF indicators, Prescribing audits.
Early Cancer Diagnosis
- Support the delivery of PCN objectives under the Early Cancer Diagnosis requirements of thePCN DES. This includes but is not limited to: attending relevant forum meetings, patient follow up from cancer screening, cancer care planning, patient communications.
Cardiovascular Disease Prevention and Diagnosis
- Support patient call and recall is directed by the Practices Quality and Compliance.
Health Inequalities
- Identify patient cohorts being targeted by the PCN / Practices, inviting them to participate inagreed interventions.
- Learning Disabilities care planning.
MDT Meetings
- Prepare the agenda for MDT meetings and contact all parties to ensure attendance and toconfirm patients to be discussed.
- Minute the MDT meetings, add notes and SNOMED codes to the patients Medical Records.
- Disseminate actions and follow-up ahead of the next meeting to ensure actions are completed.
Care Planning
- Support the Practice objectives (local and PCN-level) to ensure Care Plans are actively createdand updated. This includes for Learning Disability patients, Dementia patients, Care Homeresidents and Cancer patients.
- Identify patients without recent care plans in place and work with their name GP to updatethese plans.
- Ensure that preventative actions are agreed and detailed in Care Plans to support thereduction of unnecessary hospital admissions.
Investment and Impact Fund
- Support patient call and recall is directed by the Operations Manager Quality andCompliance.
- Ensure the minimum number of patient contacts by aligning multiple tests and reviews.
Support Data Collection:
- Effective use of the EMIS diary date to effectively manage care.
- Ensure timely and accurate collation of data for the practice and PCN.
- Maintain accurate and up to date records of patient contacts using GP record systems andother IM&T systems relevant to the role i.e. entering notes onto EMIS using agreed SNOMEDcodes.
- Appropriate management of collected data, ensuring all data is kept and shared in accordancewith all relevant governance requirements.
- Validate and quality assure incoming data.
- Run regular patient searches using EMIS in order to have an up-to-date record of progress ofachievement of Key Performance Indicators.
- Case finding to support target achievement and enhancing register prevalence.
Person Specification
Experience
Essential
- Experience of working in General Practice, the NHS or Social Care
- Understanding of current issues facing the NHS and social care process
- Experience of administrative duties
- Able to demonstrate a clear understanding of working with confidential
- information and an understanding of service user confidentiality
- Working in a multi-disciplinary setting where influence and negotiation is
- required
- Working in a busy and demanding environment whilst delivering in a timely manner
Desirable
- Knowledge/familiarity with medical terminology
- Previous experience in the Care Coordinator role.
Skills
Essential
- Proven record of excellent written and verbal communication skills and
- interpersonal skills
- Evidence of excellent knowledge of Microsoft Office
- Excellent motivational and influencing skills
- Able to prioritise and manage own workload and ensuring completion of tasks on time
- Strong analytical and judgement skills
- Ability to analyse and interpret information and present results in a clear and concise manner
Desirable
- Experienced working with EMIS Web (Medical Record system)
Qualifications
Essential
- Good standard of education with excellent literacy and numeracy skills
Desirable
- NVQ Level 3 Business Administration (or relevant experience)
Person Specification
Experience
Essential
- Experience of working in General Practice, the NHS or Social Care
- Understanding of current issues facing the NHS and social care process
- Experience of administrative duties
- Able to demonstrate a clear understanding of working with confidential
- information and an understanding of service user confidentiality
- Working in a multi-disciplinary setting where influence and negotiation is
- required
- Working in a busy and demanding environment whilst delivering in a timely manner
Desirable
- Knowledge/familiarity with medical terminology
- Previous experience in the Care Coordinator role.
Skills
Essential
- Proven record of excellent written and verbal communication skills and
- interpersonal skills
- Evidence of excellent knowledge of Microsoft Office
- Excellent motivational and influencing skills
- Able to prioritise and manage own workload and ensuring completion of tasks on time
- Strong analytical and judgement skills
- Ability to analyse and interpret information and present results in a clear and concise manner
Desirable
- Experienced working with EMIS Web (Medical Record system)
Qualifications
Essential
- Good standard of education with excellent literacy and numeracy skills
Desirable
- NVQ Level 3 Business Administration (or relevant experience)
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.
