Job summary Bay Medical Group are recruiting for a Clinical Care Co-ordinator to support patients in living well with long term health conditions. The post holder will work closely with other members of the multidisciplinary team including, but not exclusive to, nurses, GP, Pharmacists, social prescribers and third sector agencies. This is a permanent position, working full time (37.5 hours). Working pattern for the role will be: Monday to Friday 8:30 until 4:30. Main duties of the job MAIN DUTIES Identification of vulnerable and frail patients using the risk stratification, and the E-Frailty Tool (Aristotle and EMIS). Holistic assessment, planning, implementation and evaluation of the patient; encouraging self-care, resilience and community involvement as appropriate. Prioritise health problems and intervene appropriately. Sign-positing to primary, secondary, and third sector services where necessary including the voluntary sector. Working closely with clinical teams across the Practice and wider community. Working in an integrated multi-disciplinary environment across the locality, linking closely with the relevant stakeholders where appropriate, and developing patient pathways. Working closely with the Social Prescriber Care Co-ordinator to manage patient care and monitor progress against improvements following care planning and sign-posting. Attendance at the ICC Monthly Meeting and weekly MDT (Multi-Disciplinary Team) to update on the progress of patient care, including quantitative performance information around care plans, and qualitative feedback from patients. Flexibility within the Clinical Care Co-ordinator role to enable the post and the work of the Practice to evolve further, and in conjunction with the wider stakeholder group. Other duties and activities involved in patient care in line with current clinical competencies About us Bay Medical Group is a single, at scale provider of general practice services to the population of Morecambe and Heysham. We have 5 sites across the town and have a patient population of c54,000. We have an established Bay Primary Care Network (PCN) and work closely with other service providers and voluntary sector to improve the health and wellbeing of our local population. For further information about the benefits of working for us visit https://www.baymedicalgroup.co.uk/benefits We are pleased to take part on the Mind Mental Health Charity Workplace Index and receive a bronze award for the second year running as an employer achieving change. Bay Medical Group - for happier, healthier people We reserve the right to close this vacancy early if we receive sufficient applications for the role. Date posted 16 October 2024 Pay scheme Other Salary £31,520 to £35,568 a year Salary shown is pro rata based on 37.5 hours per week. Contract Permanent Working pattern Full-time Reference number A3044-24-0027 Job locations Morecambe Health Centre Hanover Street Morecambe Lancashire LA45LY Job description Job responsibilities MAIN DUTIES Identification of vulnerable and frail patients using the risk stratification, and the E-Frailty Tool (Aristotle and EMIS). Holistic assessment, planning, implementation and evaluation of the patient; encouraging self-care, resilience and community involvement as appropriate. Prioritise health problems and intervene appropriately. Sign-positing to primary, secondary, and third sector services where necessary including the voluntary sector. Working closely with clinical teams across the Practice and wider community. Working in an integrated multi-disciplinary environment across the locality, linking closely with the relevant stakeholders where appropriate, and developing patient pathways. Working closely with the Social Prescriber Care Co-ordinator to manage patient care and monitor progress against improvements following care planning and sign-posting. Attendance at the ICC Monthly Meeting and weekly MDT (Multi-Disciplinary Team) to update on the progress of patient care, including quantitative performance information around care plans, and qualitative feedback from patients. Flexibility within the Clinical Care Co-ordinator role to enable the post and the work of the Practice to evolve further, and in conjunction with the wider stakeholder group. Other duties and activities involved in patient care in line with current clinical competencies Communication Demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating Anticipate barriers to communication and take action to improve communication Act as an advocate when representing patients and colleagues Delivering a quality service Produce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures Prioritise, organise and manage own workload in a manner that maintains and promotes quality Deliver care according to NSF, NICE guidelines and evidence-based care Participate in the maintenance of quality governance systems and processes across the practice Collaborate on improving the quality of health care Support and participate in shared learning across the practice and wider organisation Understand and apply legal policy that supports the identification of vulnerable and abused children and adults, being aware of statutory child/vulnerable adult health procedure and local guidance Work within policies regarding family violence, vulnerable adults, substance abuse and addictive behaviour, and refer as appropriate Team working Understand own role and scope, and identify how this may develop over time Prioritise own workload and ensure effective time-management strategies are used. Management of risk Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines Undertake mandatory and statutory training requirements Apply infection-control measures within the practice according to local and national guidelines Apply policies that reduce environmental health risks, are culturally sensitive and increase access to health care for all Participate in the local implementation strategies that are aligned to the values and culture of general practice Utilising information Use technology as an aid to management in planning, implementation and monitoring, presenting and communicating information Review and process data using accurate SNOMED codes to ensure easy and accurate retrieval for monitoring and audit processes Understand the responsibility of self and others regarding the Freedom of Information Act Learning and development Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments Assess own learning needs and undertake learning as appropriate Make effective use of learning opportunities within and outside the workplace, evaluating their effectiveness and feeding back relevant information Provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning Job description Job responsibilities MAIN DUTIES Identification of vulnerable and frail patients using the risk stratification, and the E-Frailty Tool (Aristotle and EMIS). Holistic assessment, planning, implementation and evaluation of the patient; encouraging self-care, resilience and community involvement as appropriate. Prioritise health problems and intervene appropriately. Sign-positing to primary, secondary, and third sector services where necessary including the voluntary sector. Working closely with clinical teams across the Practice and wider community. Working in an integrated multi-disciplinary environment across the locality, linking closely with the relevant stakeholders where appropriate, and developing patient pathways. Working closely with the Social Prescriber Care Co-ordinator to manage patient care and monitor progress against improvements following care planning and sign-posting. Attendance at the ICC Monthly Meeting and weekly MDT (Multi-Disciplinary Team) to update on the progress of patient care, including quantitative performance information around care plans, and qualitative feedback from patients. Flexibility within the Clinical Care Co-ordinator role to enable the post and the work of the Practice to evolve further, and in conjunction with the wider stakeholder group. Other duties and activities involved in patient care in line with current clinical competencies Communication Demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating Anticipate barriers to communication and take action to improve communication Act as an advocate when representing patients and colleagues Delivering a quality service Produce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures Prioritise, organise and manage own workload in a manner that maintains and promotes quality Deliver care according to NSF, NICE guidelines and evidence-based care Participate in the maintenance of quality governance systems and processes across the practice Collaborate on improving the quality of health care Support and participate in shared learning across the practice and wider organisation Understand and apply legal policy that supports the identification of vulnerable and abused children and adults, being aware of statutory child/vulnerable adult health procedure and local guidance Work within policies regarding family violence, vulnerable adults, substance abuse and addictive behaviour, and refer as appropriate Team working Understand own role and scope, and identify how this may develop over time Prioritise own workload and ensure effective time-management strategies are used. Management of risk Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines Undertake mandatory and statutory training requirements Apply infection-control measures within the practice according to local and national guidelines Apply policies that reduce environmental health risks, are culturally sensitive and increase access to health care for all Participate in the local implementation strategies that are aligned to the values and culture of general practice Utilising information Use technology as an aid to management in planning, implementation and monitoring, presenting and communicating information Review and process data using accurate SNOMED codes to ensure easy and accurate retrieval for monitoring and audit processes Understand the responsibility of self and others regarding the Freedom of Information Act Learning and development Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments Assess own learning needs and undertake learning as appropriate Make effective use of learning opportunities within and outside the workplace, evaluating their effectiveness and feeding back relevant information Provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning Person Specification Experience Essential Knowledge of the work of the NHS in primary, secondary care, third sector care Knowledge of relevant legislation, including safeguarding, vulnerable adults and mental capacity Experience of delivering clinical care for patients Experience of delivering education for patients to enable self-care Experience of working within the NHS primary care Experience of care planning for patients and signposting to key support services Experience of data analysis and the ability to understand and communicate same Experience of the use of Microsoft Office Desirable Knowledge of the work of Better Care Together, the Integrated Care Communities and Primary Care Networks Knowledge of the Clinical Pathways in primary, secondary and third sector Knowledge of the NHS Long Term Plan 2019 Knowledge and understanding of the changing landscape of Health and Social Care Experience of working in secondary or third sector care Experience of change management Experience of performance measurement and monitoring of Key Performance Indicator Other Essential Flexibility to meet the needs of the service Driver with own transport Skills and Abilities Essential Ability to develop initiatives and new models of care with key stakeholders to enhance services Ability to prioritise workload Ability to work as part of a multi-disciplinary team Ability to develop skills in the use of bespoke IT systems Good communication and interpersonal skills Ability to work autonomously Ability to maintain patient confidentiality in line with the Information Governance Ability of accurately record and monitor data Ability to present confidential and sensitive information to groups Qualifications Essential Current registration as a clinical professional e.g. Nurse, Physiotherapist, Occupational Therapist Paramedic Continuing personal development clinical/ non-clinical Desirable Degree Person Specification Experience Essential Knowledge of the work of the NHS in primary, secondary care, third sector care Knowledge of relevant legislation, including safeguarding, vulnerable adults and mental capacity Experience of delivering clinical care for patients Experience of delivering education for patients to enable self-care Experience of working within the NHS primary care Experience of care planning for patients and signposting to key support services Experience of data analysis and the ability to understand and communicate same Experience of the use of Microsoft Office Desirable Knowledge of the work of Better Care Together, the Integrated Care Communities and Primary Care Networks Knowledge of the Clinical Pathways in primary, secondary and third sector Knowledge of the NHS Long Term Plan 2019 Knowledge and understanding of the changing landscape of Health and Social Care Experience of working in secondary or third sector care Experience of change management Experience of performance measurement and monitoring of Key Performance Indicator Other Essential Flexibility to meet the needs of the service Driver with own transport Skills and Abilities Essential Ability to develop initiatives and new models of care with key stakeholders to enhance services Ability to prioritise workload Ability to work as part of a multi-disciplinary team Ability to develop skills in the use of bespoke IT systems Good communication and interpersonal skills Ability to work autonomously Ability to maintain patient confidentiality in line with the Information Governance Ability of accurately record and monitor data Ability to present confidential and sensitive information to groups Qualifications Essential Current registration as a clinical professional e.g. Nurse, Physiotherapist, Occupational Therapist Paramedic Continuing personal development clinical/ non-clinical Desirable Degree 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Additional information 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Employer details Employer name Bay Medical Group Address Morecambe Health Centre Hanover Street Morecambe Lancashire LA45LY Employer's website https://www.baymedicalgroup.co.uk/ (Opens in a new tab)