Care coordinators provide extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They work closely with GPs, nurses and other primary care professionals within the PCN to identify and manage a caseload of patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. They focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.
This role is for 1 year maternity cover, with the possibility of extending.
Main duties of the job
The main responsibilities of the role include:
* Managing a caseload of identified patients with complex care needs, supporting their clinical needs by helping arrange clinical appointments and reviews, responding to queries, signposting to appropriate services and liaising with secondary care and other health services.
* Proactively identify and work with a cohort of patients to support their personalised care needs.
* Ensure patients have accurate and appropriate information to help them make choices about their care.
* Support practice recall systems, calling patients, booking appointments, chasing DNAs.
* Ensure patient records are up-to-date, working at all times within GDPR and confidentiality policies.
About us
BatterseaPCN is based in South West London and comprises of 5 GP surgeries with a combined population of approximately 57,000 patients. The PCN was set up in July 2019 as part of the NHS wide plan to support services in GP surgeries and in 2022 Battersea PCN Ltd was formed. The five practices are close geographically and enjoy excellent collaborative working relationships. Battersea PCN Ltd currently employs approximately 30 staff, both directly and through third party employers. Staff groups include a team of Clinical Pharmacists, Paramedics, Physicians Associates, Health and Wellbeing Coaches, FCPs, Associate Psychologist, Social Prescribers, and Community HWBW, plus a team of 5 Care Coordinators.
Job responsibilities
Main Responsibilities:
1. Plan and carry out patient call and recall systems for public health programmes (e.g., Covid vaccine programme, child immunisations, cervical screening), focusing particularly on vulnerable and hard to reach groups and patients with complex care needs.
2. Setting up and running clinical searches in order to monitor and focus care of target groups.
3. Manage a caseload of identified patients with complex care needs, supporting them and their clinical teams by:
* Coordinating their medical care when required.
* Responding to queries and requests for assistance.
* Sign-posting patients and carers to appropriate support services.
* Working with clinicians to ensure all the contractual requirements for patients with complex care needs are met.
* Assisting in the administration of MDT meetings and coordinating actions identified during these meetings.
1. Provide organisational and operational support for the setup of COVID vaccination clinics and other public health initiatives.
2. Proactively identify and work with a cohort of people to support their personalised care requirements.
3. Help people to manage their needs, answering their queries and supporting them to make and get to appointments.
4. Raise awareness of shared decision making and decision support tools and assist people to have shared decision-making conversations with their healthcare teams.
5. Ensure that people have good quality information to help them make choices about their care.
6. Bring together a person's identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with person centred service plan (PCSP) best practice.
7. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
8. Support the coordination and delivery of MDTs within PCNs.
9. Ensure total familiarity with the clinical system.
10. Book appointments and recalls ensuring sufficient information is recorded.
11. Code and extract data from clinical correspondence and input into EMIS Electronic Patient Record.
12. Run searches and produce reports as required with the support of practice IT teams.
13. Ensure correspondence, reports, results etc. are dealt with in a timely manner as per practice protocol.
14. Shared responsibility for target group disease register with clinical teams.
15. Receive and make calls as required answering any queries that arise.
16. Divert calls and take messages as appropriate ensuring accuracy.
17. To work at all times within the requirements of GDPR, maintaining patient confidentiality.
18. Maintain accurate clinical records at all times.
19. To participate in educational events as advised by the Practice.
20. To attend various Practice meetings as requested.
21. Any other tasks that may be required by the practice from time to time.
Person Specification
Qualifications
* GCSE Grade A to C in English and Maths (or equivalent).
* Care Certificate.
* QCF Health and Social Care.
Skills and Knowledge
* Excellent communication skills in person and over the telephone.
* Ability to provide information clearly, adapting as necessary to the needs of the patient to ensure they understand and can make informed decisions about their care.
* Able to listen with empathy and offer support where needed.
* An interest in working in primary care.
* Ability to use initiative and work unsupervised to an excellent standard.
* Flexible and hard working.
* Able to use own judgement, resourcefulness and common sense.
* Be self-motivated and enthusiastic in supporting patients to ensure they receive the best, most appropriate care possible.
* Able to quickly build rapport and trust.
* An aptitude for data gathering and reporting.
* Good working knowledge of Microsoft office (Word, Excel etc).
* Knowledge of EMIS.
* Knowledge of collaborative goal setting.
* Knowledge of the core concepts of personalised care, shared decision making, health behaviour change and motivation.
Experience
* Previous experience in primary care or other health care provider, with direct patient contact.
* Experience talking to patients over the telephone.
* Experience of working in primary care.
* Experience of working in a GP practice.
* Experience of working as a care coordinator.
* Experience of booking/arranging appointments.
* Experience of working with social prescribers or similar.
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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