Cross Gates Primary Care Network includes four practices working across seven sites: Ashfield and The Grange Medical Centre, Colton Mill and The Grange Medical Centre, Family Doctors and Manston Surgery. The PCN has a patient population of 30,000, including patients living across 5 care homes.
We believe in providing a holistic approach to managing patient care and supporting individuals to meet their own needs and aspirations. You will be part of an organization whose leadership team is supportive and innovative, focused on change and transforming services.
Our team currently includes pharmacists, pharmacy technicians, mental health practitioners, advanced clinical practitioners, admiral nurses, nurse associates, physician associates, first contact physiotherapists, health and wellbeing coaches, and care coordinators, with the aim of supporting our practices and improving health outcomes for our patients. We do this through the integration of PCN teams and services with our practices, continuous evaluation, and ongoing development of our services and projects, looking for opportunities for innovation and transformation and sharing best practice.
To address the healthcare needs of our local population, we are hoping to employ a care coordinator to join our PCN team.
Main duties of the job
Our Care Coordinators play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They work closely with practice and PCN staff to identify, engage with, and coordinate personalized care and support planning for the most vulnerable people in our community, including the frail/elderly, patients with dementia and their carers, patients diagnosed with cancer, care home residents, and those with long-term health conditions.
As well as being linked with individual practices, they will work together as a team, sharing learning and best practice both within the team and across the PCN.
Our Care Coordinators support Clinical Leads and the Multi-Disciplinary team in the organization and facilitation of MDT meetings, including weekly Care homes meetings.
About us
They run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, vaccinations, and other services including self-management services. Support with patient engagement includes ensuring that information is accessible for all and having conversations with patients and carers to increase understanding, alleviate concerns, and enhance engagement and self-management.
They support people in preparing for or following up on clinical conversations with primary care professionals (including health checks) to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.
Care Coordinators act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a person's identified care and support needs and exploring options to meet these within a single personalized care and support plan, based on what matters to the person.
Job responsibilities
1. Coordinate multidisciplinary meetings across local care organizations, including identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.
2. Provide admin support to multidisciplinary meetings, including taking minutes.
3. Utilize GP Practice clinical systems SystmOne and EMIS and population health data to proactively identify relevant cohorts of patients to deliver personalized care.
4. Support patients within these cohorts to access health checks and other health services.
5. Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system.
6. Liaise with other key stakeholders as needed for the collective benefit of the patient, including but not limited to GPs, nurses, pharmacists, and other support staff from within the PCN practices or from other provider organizations.
7. Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding.
8. Raise awareness of shared decision-making and decision support tools, and assist patients to be more prepared for shared decision-making conversations.
9. Provide coordination and navigation for patients and their carers across health and social care services, linking with social prescribers and other patient link workers in the PCN.
10. Work in partnership with key providers in the local community to enable improved access to services for patients.
11. Work with practices to support delivery of any national and local targets outlined in the GP contract.
12. Contact patients to increase uptake in designated clinics such as vaccinations, cancer screening, and health reviews, identifying reasonable adjustments that can be made for vulnerable groups of patients to provide a more suitable environment to deliver their care.
13. Coordinate case load visits for reviews or vaccinations to support the clinical team.
14. Undertake quality improvement audits to identify best practices or areas to improve and share learning across the PCN.
15. Participate in PCN workshops/training sessions relevant to the Care Coordinator role.
Person Specification
Personal Qualities
* Flexibility and adaptability to develop the role within PCN business needs.
* Demonstrate the ability to value others.
* Punctual and reliable.
* Highly motivated and enthusiastic.
* High levels of integrity and loyalty.
* Team player.
* Ability to work under pressure and timescales.
* Ability to work in an environment of change to meet the needs of primary care.
Experience
* Experience of working in a primary care setting.
* Use of clinical systems.
* Experience of working with people who may face health inequalities e.g. living with frailty, people with learning disabilities or severe mental illness, and/or carers.
* Experience of working in health, social care, or other support roles which are in direct contact with people, families, or carers.
Knowledge and Skills
* Administrative duties including preparing for meetings and writing minutes.
* Attention to detail, able to work accurately, identifying errors quickly and easily.
* Planned and organized approach with an ability to prioritize their own workload to meet strict deadlines.
* Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience.
* An excellent understanding of data protection and confidentiality issues.
* Self-motivated, pro-active, and able to work independently.
* Continued commitment to improve skills and abilities in new areas of work.
* Able to undertake the demands of the post with reasonable adjustment if required.
* Able to access transport to work across the practices within the PCN and attend meetings in other locations.
* Excellent timekeeping and prioritization skills.
* Professional attributes and appearance.
* Excellent IT skills and the ability to run reports and interpret, analyze, and present data.
* Understanding of medical technology around frailty, population health management, and long-term conditions.
Other requirements
* Flexibility to work outside of core office hours, including extended hours services.
* Hold a Valid UK Driving License and have access to own transport with business insurance and ability to travel across the locality on a regular basis, including visiting people in their own home or care home.
Qualifications
* GCSE grade A-C in Maths and English or skills level 2 in Maths and English or equivalent.
* ECDL or other equivalent IT qualification.
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.
£25,147 to £27,596 a year, depending on experience.
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