As a Care Coordinator you will be responsible for recalling and inviting patients with long term health conditions for their annual reviews, enabling patients to access health, social care and wellbeing services, professionals and information tailored to their individual needs.
You will manage a caseload of patients, guiding each patient through the various pathways and processes, facilitating actions and liaising as required.
The Care Coordinator is a key member of the Practice and PCN, working in tandem with the GPs, the nursing, administrative, reception and pharmacy teams. Additionally, linking with PCN services such as social prescribers, the home visiting service, wellbeing coaches and first contact practitioners. They play an important role in improving healthcare outcomes for patients in Coastal PCN and managing aspects of the Quality and Outcomes Framework such as long-term condition management (QOF).
Main duties of the job
Duties may be varied from time to time under the direction of the QOF lead dependent on current and evolving Practice workload and staffing levels:
1. Working with the practice and relevant PCN teams to identify cohorts of patients who require annual reviews.
2. Contact and work with these patients to organise review appointments.
3. Check and ensure each patient understands and considers the options and choices available to them.
4. Source and provide patients with relevant and appropriate information to support shared decision making.
5. Collate patient data with best practice and upload and regularly update the patient record.
6. Create, amend and use searches within the clinical system to identify cohorts of patients.
7. Create, amend and produce letter/text templates for the individual practices.
8. Produce protocols and spreadsheets to provide audit.
9. Assist the patient to navigate and progress through the relevant pathways, processes and systems, answering patient questions, making phone calls, appointments, arrangements for care, liaising with professionals, service personnel and wider stakeholders.
10. Implement a process for safety-netting at the practice, so patients are followed up effectively.
11. Ensure that knowledge of clinical IT systems is up to date and ensure the effective utilisation of these systems.
About us
Coastal Fareham and Gosport Primary Care Network (PCN) is formed of three GP practices, Brook Lane Surgery, Lockswood Surgery and Stubbington Medical Practice, and serves a population of over 39,000 patients.
The PCN aims to provide primary care of the highest quality, safety and value and improve the health and wellbeing of its population by working at individual practice level, collaboratively at PCN level and in partnership with external health, social care and community providers.
This role will be embedded in Brook Lane Surgery which is a thriving practice of 13,700 patients. Staff consists of 3 partners, 7 salaried GPs, and a team of highly skilled nurses, reception and admin staff. Brook Lane Surgery are also a training practice and regularly have GP registrars.
Job responsibilities
Main Duties and Responsibilities
1. Working with the primary care team, identify cohorts of patients who require annual reviews.
2. Contact and work with these patients to organise review appointments.
3. Check and ensure each patient understands and considers the options and choices available to them.
4. Source and provide patients with relevant and appropriate information to support shared decision making.
5. Collate patient data with best practice and upload and regularly update the patient record.
6. Be responsible for improving healthcare outcomes across the PCN by helping to lead Quality and Outcomes Framework (QOF) work in the practices.
7. Create, amend and use searches within the clinical system to identify cohorts of patients.
8. Create, amend and produce letter/text templates for the individual practices.
9. Produce protocols and spreadsheets to provide audit.
10. Assist the patient to navigate and progress through the relevant pathways, processes and systems, answering patient questions, making phone calls, appointments, arrangements for care, liaising with professionals, service personnel and wider stakeholders.
11. Implement new pathways for effective follow-up of patients with Long Term Conditions.
12. Implement a process for safety-netting at the practice, so patients are followed up effectively.
13. Ensure that knowledge of clinical IT systems is up to date and ensure the effective utilisation of these systems.
14. Be familiar with, and maintain up to date knowledge of the GP and PCN Enhanced Service requirements, in particular regarding QOF.
15. Attend regular training and webinars to keep up to date with the contract changes.
16. Work in a safe and organised manner.
17. Work with the other PCN Care Coordinators to share learning and best practice.
18. Provide cross-cover for the other care coordinators within the PCN Team at times of annual leave and sickness.
19. Build and maintain effective relationships with the practice teams and PCN staff.
20. Organise and participate in Practice management, reception and PCN Meetings.
21. Observe and comply with appropriate statutory requirements in relation to Child and Adult Safeguarding and to be familiar with the reporting process could this be required.
22. Undertake mandatory training.
23. Comply with Data Protection and Information Governance regulations and policies.
Person Specification
Experience
* Understanding of service user confidentiality.
* Experience of administrative duties.
* Experience of working with Quality Outcome Framework (QOF) targets.
* Experience of the GP contract Enhanced Services and knowledge of medical terminology.
* Experience of working in an NHS or social care organisation.
* Understanding of health and social care processes.
* Experience of SNOMED coding.
Knowledge and skills
* Proven record of excellent written and verbal communication skills as well as interpersonal skills.
* Able to deal with patients sensitively.
* Able to work as part of a team.
* Able to prioritise and manage own workload.
* Analytical skills and ability to interpret information and present it in a clear and concise manner.
* Experience of using Ardens templates/ Ardens manager software.
* Experience of using Apex.
Qualifications
* Familiar with Microsoft Office products, including Word, PowerPoint and Excel.
* EMIS experience is preferable but not essential.
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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