Whitby Coast and Moors Primary Care Network are looking to recruit an enthusiastic and compassionate Senior Care Coordinator. Our PCN is setting up a new multidisciplinary holistic care team to provide dedicated support and care for patients with complex needs. The team will care primarily, but not exclusively, for older adults.
You will have the opportunity to share in the development of this new team which will focus on health, wellbeing and independence.
You will need to have clarity of professional identity and be comfortable working with a degree of uncertainty as new services are tested and developed.
In this new team there will be plenty of opportunity to use your service development, leadership and excellent clinical skills as you work with others to improve outcomes for patients.
If you are excited by the chance to work in a brand new team designed to make a real difference to patients' lives, and based in a beautiful area, please consider this role.
Main duties of the job
This key role will be embedded in the PCN Pilot and Transformation Team within Whitby Coast and Moors Primary Care Network, which supports system-wide collaborative working to deliver multiple projects in work streams.
You will have continuing responsibility for identifying, proactive assessment, monitoring and management of patients and ensuring care is current, evidence-based and in line with practice standards. You will provide leadership to the team in evaluation and monitoring of the service, provide specialist assessment as per the service users, and carers requirements.
You will lead with other senior colleagues the continuing development of a high-quality service that is underpinned by evidence-based practice and care pathways/packages and NICE guidance.
You will be required to engage a range of key partners and stakeholders, and lead on joint working across health and social care. They will need to work closely with colleagues within the PCN, Practices and ICB, councils, and the voluntary and community sector. You will also work alongside our primary care locality groups to support them in meeting their priorities around prevention and self-care.
Job responsibilities
Key Responsibilities:
Core Clinical Function
* Provide a welcoming, compassionate, and professional service to all patients.
* Offer guidance and reassurance during procedures or assessments.
* Ensure patients' dignity, privacy, and confidentiality are respected at all times.
* Aid in identifying patients with highly complex needs who would benefit from intervention.
* Manage and oversee management and care of service users with highly complex needs.
* Produce accurate and timely documentation, conduct and manage the maintenance of accurate and timely documentation/records on all service users in line with your Professional Code of Conduct and PCN/Practice policy.
* Conduct and supervise assessment and observation to ensure appropriate and timely feedback to the team.
* Conduct, supervise and oversee risk assessments of the individual highly complex cases and the potential hazards in the service users' environment.
* Provide professional clinical input at multi-disciplinary meetings i.e. referral/review/business, professional or safeguarding meetings.
* Report and document incidents as required and act upon findings as appropriate.
* Act as a care coordinator in highly complex cases.
* Assess and review care and support and supervise lower banded staff in this process.
* Phlebotomy, Electrocardiographs (ECG's), Blood pressure monitoring, Carers reviews, NHS Health Checks, Urinalysis Health education including promoting the health benefits of a healthy diet, smoking cessation, weight management, health screening of patients with pre-Diabetes and diabetic foot checks, Ordering of clinical stock, home visits.
* Shared responsibility for teams' administration of medications, assessment of side effects, review concordance and clinical effectiveness of medication regime in line with Practice/PCN policy.
* Accurately record patient information on EMIS clinical system.
* Safe transportation and storage of medicines, checking receipt, storage of medicines.
* Providing education around the medication prescribed, side effects, actions and aids to compliance.
* Provide practical support, guidance and education for service users, carers and other professionals as required.
* Provide specialist assessment and intervention commensurate with skills and training with colleagues where required.
* Be competent in use of relevant screening and assessment tools, supervise and train lower banded staff in their use.
* Actively take part in comprehensive assessment, care planning, treatment and review of care.
* Participate in formulation, delivery and review of individualised evidence-based care/care packages according to NICE guidance including non-medication strategies.
* Lead in the continuing development of a high-quality service and contribute to local emergency plan, team risk assessment etc. that is underpinned by evidence-based practice, care pathways/packages and NICE.
* Identify, assess and manage clinical and non-clinical risks/hazards in your area through the completion of the relevant risk assessments and the implementation of risk treatment plans for inclusion in the local and PCN's risk registers.
* Undertake physical health checks of service users and ensure team acts on the findings appropriately.
* Understand the eligibility criteria and assessment process.
* Manage and coordinate multi-disciplinary meetings i.e. referral/review/business/handover in conjunction with the Clinical Lead, take a lead role in clinical service development and review.
* Identify aspects of the service which need to be improved and identify and implement appropriate changes in conjunction with the Clinical Lead.
* Participate with the Clinical Lead for the recruitment of employees in accordance with PCN Recruitment Policy and NHS Safer Recruitment Guidelines.
* In conjunction with the Clinical Lead, work within the available budget of the service and attend regular Performance Management meetings.
* Work closely with and assist the Clinical Lead with development and implementation of operational/clinical policies contributing to the formulation and review of appropriate policies.
* Deliver training where appropriate for other professionals.
* Assist the Team in the evaluation and monitoring of service in conjunction with the Clinical Lead, Clinical Director and PCN Manager.
* Ensure that the service through the implementation of performance management, all key performance indicators and targets identified by the PCN are met, and adhere to local and government initiatives.
* Responsible for the coordination and management of the team in providing a safe, effective and holistic clinical service, ensuring the delivery of high-quality care packages.
Person Specification
Qualifications
* Educated to NVQ level 2 in Health and social care in a relevant subject or equivalent level of qualification or significant equivalent previous proven experience.
* Excellent knowledge of IT systems and software programmes such as Microsoft Outlook, Word, Excel, PowerPoint, MS Teams. In addition, experience of using a range of platforms for promotion content creation.
* Qualified to NVQ level 3.
* Qualified in phlebotomy.
* Demonstrable experience in dealing with the public and dealing with sensitive and confidential information.
* Knowledge of identifying patients from clinical systems, contacting patients and organising appointments, transport for patients who require.
* A good understanding of the objectives and challenges of the PCN pilot.
* Experience of working as an HCA or care coordinator.
* Ability to assess when cases need to be escalated, stepped down or transitioned to another service, due to safeguarding or parenting capacity concerns, significant changes in need or reaching transition age.
* Ability to pull together draft reports, data, and letters.
* Ability to work with operational professionals to deliver robust multi-disciplinary and multi-agency care management.
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.
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