Job responsibilities
Job Summary:
This role is to support the smooth co-ordination of
patient care across Primary Care Networks across Surrey Heartlands geography and
GP Federations for the benefit of our patients.
The Care Coordinator will work as part of a team to deliver
administrative support to Lung Cancer Screening Programme. They will be responsible for supporting the primary care
administration of the project, recording data from the Lung Cancer service provider systems to the
relevant primary care systems, liaising with the Lung Cancer screening team, patients,
and GP practices. This will include but not limited to organising further tests,
coordinating patient-care services, and working with the care teams to evaluate
required interventions. They will also be responsible for updating GP systems
with all patient letters from the Lung cancer screening service.
Key
Responsibilities and Duties
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Input data
into the patients healthcare records as necessary
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Follow
protocols and policies mapping patient outcomes.
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Sending
regular reminders to all staff of the shifts and other routine tasks to
mitigate last-minute cancellations.
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Use Accurx to
communicate to patients outcomes of the TLHC screening programme.
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Maintain the TLHC
database with full details of actions taken and escalate any issues to the
senior team.
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Monitoring the
email inboxes & follow up on any issues raised by patients or staff issues
highlighting any concerns
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Support the services Complaints procedure
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To work across the Primary Care
Networks within the Surrey Heartland's area, as the Lung cancer screening
become active in each PCN area. To be the main point of contact for all Lung
cancer screening activity across each PCN and with all practice colleagues.
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To minimise
the impact on primary care of the Lung cancer screening activity and results
from patients scans and manage any patient-centred requirements which come to
light from those reports.
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Booking patients with mild/
moderate incidental findings for further tests using GP/Enhanced Access
appointments for any incidental findings generated from CT scans. Working up any missing components such as
blood tests etc before the GP or Practice Nurse is notified of the need to
review a patient.
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Working
with the MDTs/screening review team at the trust to ensure a smooth transfer
of patients with coding and notifications to the practice.
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To talk to
patients, and where appropriate their families and/or carers, remotely by
telephone or video. Explaining the scan results where concerns are raised and
explaining the next steps if any are required.
Care Coordination
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Overall responsibility for ensuring that the patients information is
forthcoming from both the Lung Cancer Screening providers information system to
ensure the smooth running of follow-up care of these patients within the
medical centres.
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A key role of the Care Coordinator will be to receive patient details
from the Lung Cancer screening service providers system and manage the transfer
of data onto GP systems where this is not coded automatically through ICE
Systems.
- Link to screening mobile site to ensure the
non-registered population attending on site as part of the Federation patient
registration and engagement programme.
Managing a caseload
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Identify patients who may need
support by receiving information about referrals and transfers of care from the
service and from internal practice intelligence.
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Ensure patients have
sufficient notes and codes entered into the system prior to notifying the
practice or individual GP of the CT scan reports.
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Maintaining access to the Lung
cancer screening service provider information System alongside the screening
administrator to ensure seamless transfer of care.
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Help patients understand their condition and the need for any follow-up
actions, including blood tests by liaising with clinical colleagues. Aim for
patients to have specific instructions regarding follow-up activities.
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With the help of relevant clinical colleagues, develop a care plan to
address patients personal health care needs in relation to CT scan reports.
Ensure care plans are uploaded to all relevant systems for sharing with other
providers, including SystmOne and ShareMyCare.
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Promote clear communication
amongst a care team and treating clinicians by ensuring awareness regarding
patient care plans and the reasons for their creation.
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Assist and empower the
patient to consult and collaborate with other health care providers and
specialists to set up patient appointments and treatment plans.
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Alert the line manager to any issues compromising the quality
of projects and operational work streams
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Be responsible for
liaising with relevant managers and coordinating incident, complaint and
compliment logging, investigation and reporting, ensuring that the appropriate
actions are taken and learning shared within the service and across partner
organisations where appropriate
Linking with other services
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Signpost team members, service users and carers to relevant services
including the PCN Social Prescribing Link Worker Service.
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Liaise with the Social
Prescriber regarding patients that are identified as needing well-being support.
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Liaise with PCN clinicians responsible
for frailty regarding patients that are identified as needing ongoing support.
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Liaise with acute trusts, hospices,
community and social care providers as required.
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Arranging,
coordinating and minute taking for any key governance meetings; ensure that
responsible managers provide reports to support these meetings. You will be expected to travel across Surrey
Heartlands.
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Liaising with relevant services
who may support patients through a holistic approach. This could include
services such as stop smoking, exercise groups and psychosocial support.
Record Keeping
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Keep accurate and up-to-date
records of contact with patients, carers and professionals, including use of
SystmOne or EMIS to record patient contact on the medical record.
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Use accurate SNOMED codes to
record patient contacts and interventions, mainly via the use of existing templates,
for audit purposes and monitoring and measuring outcomes.
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Report case studies and
outcomes to the PCN at the end of the PCN live screening cycle.
General Responsibilities
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Work
as part of the team to seek feedback, continually improve the service and contribute to business planning.
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Undertake
any tasks consistent with the level of the post and the scope of the role, ensuring that work is
delivered in a timely and effective manner.
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Attend
ongoing training and courses to keep abreast of new developments in health care
as required by the PCN and Federation.
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Treat
patients with empathy and respect and conduct oneself in a professional manner.
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Attend and contribute to
relevant meetings.
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To be able to be
flexible with working hours including weekends and evenings
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Work
collaboratively to help develop and promote a positive working culture,
encouraging staff participation and involvement in developing, improving and
promoting the service.
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Duties may vary from time to
time, without changing the general character of the post or the level of responsibility.
Confidentiality
We consider confidentiality
and ensure minimal and appropriate usage of all data we hold and access, to
comply with NHS Information Governance frameworks.
We ask staff to be vigilant
about both their safety and the patients, taking necessary action, as
required, and feeding back any concerns so that we can make improvements.
Equal Opportunities
The organisation values the
rich diversity, skills and abilities that people from differing backgrounds and
experiences bring to the workplace. Implementing and abiding by a policy that
provides for diversity and equal opportunities and deters unlawful
discrimination is therefore important to this organisation.
Technology
We use a selection of computer
technology systems and tools. Staff should expect to use automated information
systems in their work to improve quality, efficiency and service coordination,
and to enable faster and more accurate communication internally and externally.
Health and Safety
At DHC federation, we
recognise the need to comply with the
Health and Safety at Work etc.
Act 1974 and understand this is a legal requirement, not a matter of choice. We
will continuously strive to fulfil our responsibilities for all matters
pertaining to health and safety.
Furthermore, we will ensure
all our staff are fully aware of their individual and collective
responsibilities and that they are committed to maintaining a positive and proactive
approach to minimising risk.
Training and Development
We ensure that people have the
information, equipment and skills they need to do their work. This includes
bespoke training opportunities based on identified gaps and agreed priorities
with the team (e.g., Human Factors, trauma-informed care; Non-Violent
Communication).
