Job summary
You will work with GP practice teams to coordinate the care of patients with frailty, cancer,
long term conditions, safeguarding and social issues, patients requiring proactive care, and
patients who require support to communicate effectively. You will liaise with the patient,
practice team, secondary care teams, social services, the voluntary and community sector,
and other members of the Primary Care Network team to help smooth the patients
pathway, expedite care where appropriate, and follow up letters and results.
You will support the practice to deliver good quality care for frail patients, patients in
palliative care, and patients with long term conditions. You will work with the practice team
to prepare for effective GSF and frailty meetings, and ensure that processes such as falls
assessments and medication reviews are carried out in a timely manner. Where appropriate,
you will help develop a personalised care and support plan for these patients. You will
support the practice to ensure that patients are reviewed at an appropriate frequency, and
to achieve QOF, IIF, and LIAISE targets.
You will be working as part of the Teesdale PCN team to support the patients of up to 6 GP
practices.
Main duties of the job
Part time; 18.75 hours.
Work with practice teams to coordinate care for patients with greater needs, to
improve the patient pathway and expedite care
Proactively identify patients who require care coordination, using agreed criteria and
population health tools
Support the achievement of practice quality standards including QOF, IIF, and LIAISE
Work closely and in partnership with the Social Prescribing Link Workers, to address
wider determinants of health. Help patients manage their needs through answering queries, making and managing
appointments.
Assist people to access personal health budgets
Encouraging uptake of QOF LTC Annual and Structured Medication Reviews
Encouraging the delivery of good quality annual health checks for patients with
learning disabilities and SMI.
Supporting the practice in delivering its IIF priorities
Supporting cancer screening, including FIT tests/bowel screening, cervical screening,
and breast screening. Refer smokers to smoking cessation. Safety netting two week
wait referrals
Coordinating and following up of referrals
Coordinating GSF, safeguarding, and MDT meetings. Work with
these patients and other groups as identified by the Practice to help with timely care
navigation and coordination across primary & secondary health and social care
services. Share decision aids such as information on Vaccines, Cancer, Personal health
budgets, frailty, Macmillan, Join the dots, CAB, Care connect, Stop smoking, Drug &
alcohol services, Talking changes.
About us
A group of 12 GP
practices across Durham Dales got together, looking for a solution to help them
provide the care patients needed, share resources and ideas, and be prepared
for the challenges the NHS would face in the future. The answer they came up
with was a formal collaboration between the dozen practices: the Durham Dales
Health Federation. DDHFs founding principal is to work together to provide
high-quality, cost effective primary healthcare services. That means providing
a range of services that all GP practices in the area can use to help look
after patients. We employ a range of clinical staff pharmacists, dispensers,
nurses, emergency care practitioners and social prescribing link workers as
well as non-clinical, administration support staff.
Benefits DDHF can
offer; paid mileage. NHS pension. A car lease scheme which is transferable. We
fully support training & development. Regular 1-2-1 support &
appraisal. Cycle to work Scheme (salary sacrifice bike). Complimentary refreshments. Free Car Park, Health
service discounts, Immunisations offered, Eye tests reimbursed.
Job description
Job responsibilities
Job responsibilities
Work with practice
teams to coordinate care for patients with greater needs, to improve the
patient pathway and expedite care as appropriate
Proactively
identify patients who require care coordination, using agreed criteria and
population health tools as appropriate
Support the
delivery of the practice GSF and frailty programmes
Support the
achievement of practice quality standards including QOF, IIF, and LIAISE
Work closely and in
partnership with the Teesdale Social Prescribing Link Workers, to assist
patients to take up training and employment and access benefits
Help patients
manage their needs through answering queries, making and managing appointments,
and ensuring that people have access to good quality information about their
care
Assist people to
access personal health budgets where appropriate
Coordinate
appointments and encourage uptake of vaccinations in eligible populations
Utilise and
demonstrate sensitive communication styles, to ensure patients are fully
informed and consent to treatment
Support patients to
use decision aids in preparation for shared decision making conversations
Communicate
effectively with patients and carers, recognising the need for alternative
methods of communication to overcome different levels of understanding,
cultural background and preferred ways of communicating
Anticipate barriers
to communication and take action to improve communication
Maintain effective
communication within the PCN and with external stakeholders
Job description
Job responsibilities
Job responsibilities
Work with practice
teams to coordinate care for patients with greater needs, to improve the
patient pathway and expedite care as appropriate
Proactively
identify patients who require care coordination, using agreed criteria and
population health tools as appropriate
Support the
delivery of the practice GSF and frailty programmes
Support the
achievement of practice quality standards including QOF, IIF, and LIAISE
Work closely and in
partnership with the Teesdale Social Prescribing Link Workers, to assist
patients to take up training and employment and access benefits
Help patients
manage their needs through answering queries, making and managing appointments,
and ensuring that people have access to good quality information about their
care
Assist people to
access personal health budgets where appropriate
Coordinate
appointments and encourage uptake of vaccinations in eligible populations
Utilise and
demonstrate sensitive communication styles, to ensure patients are fully
informed and consent to treatment
Support patients to
use decision aids in preparation for shared decision making conversations
Communicate
effectively with patients and carers, recognising the need for alternative
methods of communication to overcome different levels of understanding,
cultural background and preferred ways of communicating
Anticipate barriers
to communication and take action to improve communication
Maintain effective
communication within the PCN and with external stakeholders
Person Specification
Experience
Essential
- Experience of providing and receiving complex, sensitive information
Desirable
- Experience working in a primary care setting
Qualifications
Essential
- GCSE Grade A-C in Maths & English or
- skills level 2 Maths & English or equivalent
Desirable
- Qualification in a health or social care allied profession
Knowledge & Skills
Essential
- Demonstrate an appreciation of the health needs of patients in the Teesdale area
- Communication skills, both written and verbal
- Empathy with the patients needs and conditions
- Positive attitude to work, colleagues and patients
- Non-judgemental attitude to patients
- Tact and diplomacy
- Desire to help and put people first
- Ability to negotiate the best possible services for patients
- Advocacy skills
- Time management
- Team working
- Good IT keyboard skills
Desirable
- Knowledge of community based primary care issues
- Knowledge of primary care networks and collaborative ways of working
- Understanding of safeguarding principles.
- Knowledge of SystmOne information system
Other
Essential
- Full UK driving Licence
- Willingness to travel between GP practices and work from various locations in the Dales area
- Highly motivated
- Enthusiastic and confident
- 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.
Person Specification
Experience
Essential
- Experience of providing and receiving complex, sensitive information
Desirable
- Experience working in a primary care setting
Qualifications
Essential
- GCSE Grade A-C in Maths & English or
- skills level 2 Maths & English or equivalent
Desirable
- Qualification in a health or social care allied profession
Knowledge & Skills
Essential
- Demonstrate an appreciation of the health needs of patients in the Teesdale area
- Communication skills, both written and verbal
- Empathy with the patients needs and conditions
- Positive attitude to work, colleagues and patients
- Non-judgemental attitude to patients
- Tact and diplomacy
- Desire to help and put people first
- Ability to negotiate the best possible services for patients
- Advocacy skills
- Time management
- Team working
- Good IT keyboard skills
Desirable
- Knowledge of community based primary care issues
- Knowledge of primary care networks and collaborative ways of working
- Understanding of safeguarding principles.
- Knowledge of SystmOne information system
Other
Essential
- Full UK driving Licence
- Willingness to travel between GP practices and work from various locations in the Dales area
- Highly motivated
- Enthusiastic and confident
- 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.
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.
Employer details
Employer name
Durham Dales Health Federation
Address
Unit 51 Innovation Hse, Longfield Rd
South Church Enterprise Park
Bishop Auckland
Durham
DL14 6XB
Employer's website
https://ddhf.co.uk/ (Opens in a new tab)
