Job summary
This exciting opportunity has arisen from successful bidsfor funding from the Deep End project, which looks to support "deepend" practices whose patients are more likely to experience healthinequalities due to living in areas of high deprivation.
In your role you will work as part of thewider practice and PCN teams and will be aligned to specific practice(s). You will be responsible for co-ordinating,integrating and delivering support to the practices patients.
You will ensure patients have good quality information to help them make informed choices about relevant screening and vaccination programmes by liaising with a broad range of medical, social and third sector services.
Main duties of the job
You will ensure effective, co-ordinated care is available to thesepatients, proactively identifying their personalised care needs, using decisionsupport aids as required. You will bringtogether the patients identified care/ support needs and explore with them optionsto meet their needs, recording them in a single personalised care and supportplan (PCSP).
You will work with patients, their families and carers, to improvetheir health and wellbeing by encouraging uptake opportunities, ensuring theyhave good quality information to support their decision making, by taking aholistic approach.
By using Population Health Intelligence, the service may be targetedat specific patient groups, identified by the GP practices in the PCN. Thesepatients will include but are not limited to: adults with complex long term health needs,depression, organic mental illness, and those who are at risk of socialisolation.
You will be responsible to act on any follow up requirements, ensuringpatients are aware of any additional monitoring or tests that are required andthe timescales.
You will be working at a variety of venues in general practice and thecommunity, including patients homes.
You will work collaboratively with the general practice teams to meetthe needs of patients, alongside social prescribing link workers, to supportthe delivery of co-ordinated care.
About us
South Durham Health Federation member practice's; BevanMedical Group, Southdene Medical Centre and Horden Group Practice are lookingto recruit two full-time care coordinators on a fixed-term basis to deliverproactive interventions to over 20,000 patients.
We are committed to the ongoing development of our teams, which includes mandatory and developmental training.
Job description
Job responsibilities
Service Delivery
You will build and develop a robust knowledge and understanding ofvarious cancer screening and vaccination programmes in line with NHS Englandrecommendations.
Proactively identify and work with people, whoengage with the practice irregularly and those who fail to engage with smearprogrammes, child vaccinations etc. Create a recall system for follow up's.
Develop relationships with the hard- to- reachgroups and understand how the practice can adapt to better understand and meettheir needs.
Help people to manage their needs throughanswering queries, making, and managing appointments, and ensuring that peoplehave good quality written or verbal information to help them make choices abouttheir care.
Work closely with the wider practice teams,making sure that appropriate clinical support is made available to people.
Appropriately navigate patients across healthservices, utilizing other personalised care roles such as Social PrescribingLink Workers and health coaches ensuring most appropriate support.
Communication
Attend aligned practice level MDT meetings to discuss patients andcoordinate with other care providers as required.
Utilise and demonstrate sensitivecommunication styles, to ensure patients are fully informed.
Communicate with and support patients who are receiving bad news.
Communicate effectively with patients and carers, recognising the needfor alternative methods of communication to overcome different levels ofunderstanding, cultural background and preferred ways of communicating.
Anticipate barriers to communication and take action to overcome this.
Maintain effective communication within the practice environment andwith external stakeholders.
Delivering a qualityservice
Produce accurate, contemporaneous and complete records of patientcontact, consistent with legislation, policies and procedures.
Prioritise, organise and manage own workload in a manner that maintainsand promotes quality.
Assess effectiveness of care delivery through self and peer review,benchmarking and formal evaluation.
Participate in the maintenance of quality governance systems andprocesses across the organisation and its activities.
Utilise the audit cycle as a means of evaluating the quality of the workof self and the team, implementing improvements where required.
Support and participate in shared learning across the wider organisation.
Understand and apply legal issues that support the identification ofvulnerable and abused adults, and be aware of statutory vulnerable patientshealth procedures and local guidance.
The post holder will comply with the organisations policiesand procedures:
CollaborativeWorking Relationships
Understand your own role and scope, work within this scope of practiceand identify how this may develop over time.
Work as an effective and responsible team member, supporting others andexploring the mechanisms to develop new ways of working.
Create clear referral mechanisms to meet patient need.
Prioritise own workload and ensureeffective time-management strategies are embedded.
Work effectively with others to clearly define values, direction andpolicies impacting upon care delivery.
Discuss, highlight and work with the team to create opportunities toimprove patient care.
Liaise with other stakeholders as needed forthe collective benefit of patients.
Recognise personal limitations and refer tomore appropriate colleagues when necessary.
Foster and maintain strong links with servicesacross locality.
Explore the potential for collaborativeworking and take opportunities to initiate and sustain such relationships.
Managing information
Use technology and appropriate software as an aid to management inplanning, implementation and monitoring of care, presenting and communicatinginformation.
Ensure that patient data is kept confidential at all times and is sharedon a need to know basis only.
Understand responsibility of self and others regarding the Freedom ofInformation Act
Collate, analyse and present data and information to theteam.
Education,Training and Development
Disseminate learning and information gained to other team members inorder to share good practice and inform others about current and futuredevelopments ( courses and conferences).
Assess own learning needs and undertake learning as appropriate.
Demonstrate self-development throughcontinuous professional development activity; working alongside colleagues toidentify areas to develop.
Equality and Diversity
You must co-operate with all policies andprocedures designed to ensure equality of employment. Co-workers, patients and visitors must betreated equally irrespective of gender, ethnic origin, age, disability, sexualorientation, religion etc.
You must demonstrate respect for patientconfidentiality at all times
You should respect patient confidentiality atall times and not divulge patient information unless sanctioned by therequirements of the role.
SpecialWorking Conditions
You will be required to travel independentlybetween practice sites (where applicable), patients homes, community settings andto attend meetings with other agencies. Ability to drive and access to avehicle will be required.
JobDescription Agreement
This job description is intended to provide anoutline of the key tasks and responsibilities only. There may be other dutiesrequired of the post-holder commensurate with the position. This descriptionwill be open to regular review and may be amended to take into accountdevelopment within the network. All members of staff should be prepared to takeon additional duties or relinquish existing duties in order to maintain theefficient running of the network.
This job description is intended as a basicguide to the scope and responsibilities of the post and is not exhaustive. Itwill be subject to regular review and amendment as necessary in consultationwith the post-holder.
Healthand Safety/Risk Management
You must comply at all times with thePractices Health and Safety policies, in particular by following agreed safeworking procedures and reporting incidents using the organisations IncidentReporting System.
You must comply with the Data Protection Act(2018) and the Access to Health Records Act (1990).
Person Specification
Experience
Essential
1. Demonstrate an appreciation of the health needs of the patient population within the Primary care network.
2. Communication skills, both written and verbal
3. Empathy with a variety of patients needs and conditions
4. Positive attitude to work, colleagues and patients
5. Non-judgemental attitude to patients
6. Tact and diplomacy
7. Desire to help and put people first
8. Ability to negotiate the best possible services for patients
9. Advocacy skills
10. Time management
11. Team working approach
12. Good IT keyboard skills
13. Experience of working with the public.
Desirable
14. Knowledge of SystmOne
15. Experience of working in social care or health services.
16. Knowledge of the geographical area within the Primary care Network.
17. Understanding of safeguarding principles.
18. Knowledge of local health and social care provision
19. Knowledge of funding systems in social care
Qualifications
Essential
20. GCSE Grade C or above in Maths and English, or equivalent qualification.
Desirable
21. Qualification in a health or social care allied profession.
Other
Essential
22. Ability to travel between practices and carry out home visits.
23. Highly motivated
24. Flexible
25. Enthusiastic
26. Team player
27. Immunisation status
28. UK Work Permit (if required)
Desirable
29. In date DBS check (new DBS will be undertaken on appointment)
30. Previous training in Safeguarding adult and children (training will be undertaken on appointment)