Job summary
Our Care Coordinators play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They work closely with practice and PCN staff to identify, engage with and coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, patients with dementia and their carers, patients diagnosed with cancer, care home residents and those with long-term health conditions.As well as being linked with individual practices they will work together as a team. This includes sharing learning and best practice both within the team and across the PCN.Our Care Coordinators support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings including weekly Care homes meetings.They run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, vaccinations and other services including self-management services. Support with patient engagement, which includes ensuring that information is accessible for all and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.They support people in preparing for or following-up clinical conversations with primary care professionals (including health checks) to enable them to be actively involved in managing their care and supported to make choices that are right for them.
Main duties of the job
Coordinate multidisciplinary meetings across local care organisations including identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.Provide admin support to multidisciplinary meetings including taking minutes.Utilise GP Practice clinical systems (SystmOne and EMIS) and population health data to proactively identify relevant cohorts of patients to deliver personalised care.Support patients within these cohorts to access health checks and other health services including conducting blood pressure (BP) checks and phlebotomy (blood sample collection) where appropriate.Assist with the collection of clinical observations such as BP, pulse, oxygen saturation, and other basic health indicators to support patient monitoring.Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system.Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations.Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding.To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers.
About us
Cross Gates Primary Care Network includes four practices working across seven sites: Ashfield and The Grange Medical Centre, Colton Mill and The Grange Medical Centre, Family Doctors and Manston and Surgery. The PCN has a patient population of 30,000 including patients living across 5 care homes.
We believe in providing a holistic approach to managing patient care and supporting individuals to meet their own needs and aspirations. You will be part of an organisation whose leadership team are supportive and innovative, focused on change and transforming services.
Our team currently includes pharmacists, pharmacy technician, mental health practitioners, advanced clinical practitioner, admiral nurse, nurse associate, physician associate, first contact physiotherapists, health and wellbeing coaches and care coordinators, with the aim of supporting our practices and improving health outcomes for our patients. We do this through the integration of PCN teams and services with our practices, continuous evaluation, and ongoing development of our services and projects, looking for opportunities for innovation and transformation and sharing best practice.
To address the healthcare needs of our local population we are hoping to employ a care coordinator to join our PCN team.
Job description
Job responsibilities
Ashfield Medical Centre Colton Mill Medical Centre Family Doctors Manston Surgery
Job Summary
Our Care Coordinators play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They work closely with practice and PCN staff to identify, engage with and coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, patients with dementia and their carers, patients diagnosed with cancer, care home residents and those with long-term health conditions.
As well as being linked with individual practices they will work together as a team. This includes sharing learning and best practice both within the team and across the PCN.
Our Care Coordinators support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings including weekly Care homes meetings.
They run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, vaccinations and other services including self-management services. Support with patient engagement, which includes ensuring that information is accessible for all and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.
They support people in preparing for or following-up clinical conversations with primary care professionals (including health checks) to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.
Care Coordinators act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a persons identified care and support needs and
Job description
Job responsibilities
Ashfield Medical Centre Colton Mill Medical Centre Family Doctors Manston Surgery
Job Summary
Our Care Coordinators play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They work closely with practice and PCN staff to identify, engage with and coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, patients with dementia and their carers, patients diagnosed with cancer, care home residents and those with long-term health conditions.
As well as being linked with individual practices they will work together as a team. This includes sharing learning and best practice both within the team and across the PCN.
Our Care Coordinators support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings including weekly Care homes meetings.
They run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, vaccinations and other services including self-management services. Support with patient engagement, which includes ensuring that information is accessible for all and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.
They support people in preparing for or following-up clinical conversations with primary care professionals (including health checks) to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.
Care Coordinators act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a persons identified care and support needs and
Person Specification
Other Requirements
Essential
- Flexibility to work outside of core office hours including extended hours services
- Disclosure Barring Service (DBS) check
- Hold a Valid UK Driving License and have access to own transport with business insurance and ability to travel across the locality on a regular basis, including visiting people in their own home or care home.
Experience
Essential
- Administrative duties including preparing for meetings and writing minutes
- Has attention to details, able to work accurately, identifying errors quickly and easily
- Has a planned and organised approach with an ability to priority their own workload to meet strict deadlines
- Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience
- An excellent understanding of data protection and confidentiality issues
- Self-motivated, pro-active and able to work independently
- Continued commitment to improve skills and abilities in new areas of work
- Able to undertake the demands of the post with reasonable adjustment if required
- Able to access transport to work across the practices within the PCN and attend meetings in other locations
- Excellent time keeping and prioritisation skills
- Professional attributes and appearance
- Excellent IT skills and the ability to run reports and interpret / analyse and present data
Desirable
- Understanding of medical technology around frailty, population health management and long term conditions
- Perform venapunture
- Perform basic physiological observations including BP, Pulse checks, Sats, respiration and Peak Flow Readings
Qualifications
Essential
- GCSE grade A-C in Maths and English or skills level 2 in Maths and English (or equivalent)
Desirable
- NVQ level 3 in healthcare
- ECDL or other equivalent IT qualification
Person Specification
Other Requirements
Essential
- Flexibility to work outside of core office hours including extended hours services
- Disclosure Barring Service (DBS) check
- Hold a Valid UK Driving License and have access to own transport with business insurance and ability to travel across the locality on a regular basis, including visiting people in their own home or care home.
Experience
Essential
- Administrative duties including preparing for meetings and writing minutes
- Has attention to details, able to work accurately, identifying errors quickly and easily
- Has a planned and organised approach with an ability to priority their own workload to meet strict deadlines
- Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience
- An excellent understanding of data protection and confidentiality issues
- Self-motivated, pro-active and able to work independently
- Continued commitment to improve skills and abilities in new areas of work
- Able to undertake the demands of the post with reasonable adjustment if required
- Able to access transport to work across the practices within the PCN and attend meetings in other locations
- Excellent time keeping and prioritisation skills
- Professional attributes and appearance
- Excellent IT skills and the ability to run reports and interpret / analyse and present data
Desirable
- Understanding of medical technology around frailty, population health management and long term conditions
- Perform venapunture
- Perform basic physiological observations including BP, Pulse checks, Sats, respiration and Peak Flow Readings
Qualifications
Essential
- GCSE grade A-C in Maths and English or skills level 2 in Maths and English (or equivalent)
Desirable
- NVQ level 3 in healthcare
- ECDL or other equivalent IT qualification
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.
