You will work with GP practice teams to coordinate the care of patients with frailty, cancer, long term conditions, safeguarding and social issues, patients requiring proactive care, and patients who require support to communicate effectively. You will liaise with the patient, practice team, secondary care teams, social services, the voluntary and community sector, and other members of the Primary Care Network team to help smooth the patient pathway, expedite care where appropriate, and follow up letters and results. You will support the practice to deliver good quality care for frail patients, patients in palliative care, and patients with long term conditions. You will work with the practice team to prepare for effective GSF and frailty meetings, and ensure that processes such as falls assessments and medication reviews are carried out in a timely manner. Where appropriate, you will help develop a personalised care and support plan for these patients. You will support the practice to ensure that patients are reviewed at an appropriate frequency, and to achieve QOF, IIF, and LIAISE targets. You will be working as part of the Teesdale PCN team to support the patients of up to 6 GP practices.
Main duties of the job
Part time; 18.75 hours.
1. Work with practice teams to coordinate care for patients with greater needs, to improve the patient pathway and expedite care.
2. Proactively identify patients who require care coordination, using agreed criteria and population health tools.
3. Support the achievement of practice quality standards including QOF, IIF, and LIAISE.
4. Work closely and in partnership with the Social Prescribing Link Workers, to address wider determinants of health. Help patients manage their needs through answering queries, making and managing appointments.
5. Assist people to access personal health budgets.
6. Encouraging uptake of QOF LTC Annual and Structured Medication Reviews.
7. Encouraging the delivery of good quality annual health checks for patients with learning disabilities and SMI.
8. Supporting the practice in delivering its IIF priorities.
9. Supporting cancer screening, including FIT tests/bowel screening, cervical screening, and breast screening. Refer smokers to smoking cessation. Safety netting two week wait referrals.
10. Coordinating and following up of referrals.
11. Coordinating GSF, safeguarding, and MDT meetings. Work with these patients and other groups as identified by the Practice to help with timely care navigation and coordination across primary & secondary health and social care services. Share decision aids such as information on Vaccines, Cancer, Personal health budgets, frailty, Macmillan, Join the dots, CAB, Care connect, Stop smoking, Drug & alcohol services, Talking changes.
About us
A group of 12 GP practices across Durham Dales got together, looking for a solution to help them provide the care patients needed, share resources and ideas, and be prepared for the challenges the NHS would face in the future. The answer they came up with was a formal collaboration between the dozen practices: the Durham Dales Health Federation. DDHF's founding principle is to work together to provide high-quality, cost effective primary healthcare services. That means providing a range of services that all GP practices in the area can use to help look after patients. We employ a range of clinical staff pharmacists, dispensers, nurses, emergency care practitioners and social prescribing link workers as well as non-clinical, administration support staff.
Benefits DDHF can offer; paid mileage, NHS pension, a car lease scheme which is transferable, fully support training & development, regular 1-2-1 support & appraisal, cycle to work scheme (salary sacrifice bike), complimentary refreshments, free car park, health service discounts, immunisations offered, eye tests reimbursed.
Job responsibilities
Job responsibilities
1. Work with practice teams to coordinate care for patients with greater needs, to improve the patient pathway and expedite care as appropriate.
2. Proactively identify patients who require care coordination, using agreed criteria and population health tools as appropriate.
3. Support the delivery of the practice GSF and frailty programmes.
4. Support the achievement of practice quality standards including QOF, IIF, and LIAISE.
5. Work closely and in partnership with the Teesdale Social Prescribing Link Workers, to assist patients to take up training and employment and access benefits.
6. Help patients manage their needs through answering queries, making and managing appointments, and ensuring that people have access to good quality information about their care.
7. Assist people to access personal health budgets where appropriate.
8. Coordinate appointments and encourage uptake of vaccinations in eligible populations.
9. Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment.
10. Support patients to use decision aids in preparation for shared decision making conversations.
11. 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.
12. Anticipate barriers to communication and take action to improve communication.
13. Maintain effective communication within the PCN and with external stakeholders.
Person Specification
Experience
* Experience of providing and receiving complex, sensitive information.
* Experience working in a primary care setting.
Qualifications
* Skills level 2 Maths & English or equivalent.
* Qualification in a health or social care allied profession.
Knowledge & Skills
* Demonstrate an appreciation of the health needs of patients in the Teesdale area.
* Communication skills, both written and verbal.
* Empathy with the patients' needs and conditions.
* Positive attitude to work, colleagues and patients.
* Non-judgemental attitude to patients.
* Tact and diplomacy.
* Desire to help and put people first.
* Ability to negotiate the best possible services for patients.
* Time management.
* Knowledge of community based primary care issues.
* Knowledge of primary care networks and collaborative ways of working.
* Understanding of safeguarding principles.
* Knowledge of SystmOne information system.
Other
* Full UK driving Licence.
* Willingness to travel between GP practices and work from various locations in the Dales area.
* Highly motivated.
* Enthusiastic and confident.
* 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.
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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