The Clinical Care Coordinator will be employed by Tadcaster & Selby Rural (TaSR) PCN to work on behalf of the three member Practices (South Milford Surgery, Tadcaster Medical Centre, and Sherburn Group Practice). TaSR PCN has a sizable cohort of patients eligible for an NHS Health Check, as well as using population health management to target patients for preventable measures. The role would also be responsible for the physical clinical measures, data gathering, and support of the population of Learning Disabilities and Severe Mental Illness patients.
Main duties of the job
The PCN wishes to support the engagement of attendance to NHS Health Check appointments as part of individual Practice targets. The Clinical Care Coordinator would support the identification of patients through to the end consultation of patients in Practice clinics (to include basic clinical skills such as taking blood pressure, phlebotomy, height, weight, urine dip, and lifestyle questions). The role will provide the Practices with additional capacity to achieve targets as well as providing clinical support. The role will be mainly based in Practice and supervised by the Lead Nurses of such.
The role will also focus on a large cohort of patients who have a Learning Disability or a form of Severe Mental Illness. These patients often don't engage with medical services. It is the role of the Clinical Care Coordinator to work with the PCN admin team to engage these patients and see them in clinic for part of their reviews. Whilst at the reviews, encouraging uptake on screening, annual reviews, medication compliance, and attendance at further reviews linked to their disability or mental health issue.
The role is also responsible for assisting with care home Personalised Care Support Plans (PCPS); visits to homes will be undertaken every 6 weeks to capture data on new residents and put into a plan.
The role may also provide additional phlebotomy support in busier months where required in addition to other duties as set out by the PCN Manager and Practice Management team.
Job responsibilities
Job Summary
The aims of the role are to:
1. Provide additional support to PCN member Practices in the delivery of the NHS Health Check by providing non-clinical admin support (bookings) and clinical support (in Practice clinics).
2. Engage, support, and see LD and SMI patients.
3. Support the delivery of the PCN Directed Enhanced Service (DES) and Impact and Investment Fund (IIF) and Quality Outcomes Framework (QoF).
The role will work closely with existing GP practices multi-disciplinary team structures ensuring the patient experience remains central to every stage of their journey.
The post holder will work with the multi-disciplinary team to ensure that all requests for support or patients' needs are assessed and put into action wherever appropriate.
1. Provide additional capacity for Practices by supporting the clinical basic NHS Health checks in addition to other clinical duties as directed by the Practice teams.
2. Provide a single point of contact to staff to navigate with reference to LD and SMI patients.
3. Follow up on blood results for patients who have had an NHS Health Check (QRisks).
4. Carry out basic clinical observations to include phlebotomy, blood pressure checks, height, and weight.
5. Undertake any other clinical skills at the request of the Practices (if competent to do so).
6. Assist with the delivery of seasonal Covid vaccinations (if competent to do so).
7. Run and manage own rotas where appropriate.
8. Ensure the designated caseload is professionally managed and that the care and treatment provided is in line with Practice policies and procedures.
9. Conduct duties in a way that reduces impact on Practice activities and increases overall capacity.
10. Ensure the appropriate action is taken to safeguard adults and vulnerable patients. This will include attending regular safeguarding meetings if required and ensuring statutory and mandatory training is up to date.
11. Coordinate inputs to advance care plans ensuring high-risk patients are discussed at MDT meetings if needed.
12. Produce reports of NHS Health Check uptake and engagement as well as other reports at the request of the PCN team.
13. Identify patients and produce reports on those who would benefit from early intervention.
14. Ensure a coordinated approach to service delivery at all PCN sites to promote good working relationships.
15. Ensure Statutory and Mandatory training is kept up to date as well as any additional CPD at the request of the PCN Practices.
Your role will involve but not be limited to performing the above.
Monitoring and Reporting
Assist in the production of NHS reports.
Provide quarterly reports to the PCN Manager and PCN Board.
Provide regular updates to Clinical Leads.
Personal/ Professional Development
Participate in any training programme implemented by the Practice as part of this employment such training to include:
* Participation in an annual individual performance review including taking responsibility for maintaining a record of own personal and / or professional development.
* Taking responsibility for own development, learning, and performance and demonstrating skills and activities to others who are undertaking similar work.
Quality
Strive to maintain quality within GP Practices and:
* Alert other team members to issues of quality and risk.
* Assess own performance and take accountability for own actions either directly or under supervision.
* Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team's performance.
* Work effectively with individuals in other agencies to meet patients' needs.
* Effectively manage own time, workload, and resources.
Communication
Recognise the importance of effective communication within the team and strive to:
* Communicate effectively with other team members.
* Communicate effectively with patients and carers.
* Recognise people's needs for alternative methods of communication and respond accordingly.
Person Specification
Experience
* Experience within General Practice.
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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