We are looking for a skilled, experienced and enthusiastic team member, to work within our evolving team at Lincoln Healthcare Partnership Primary Care Network (PCN). A team with a goal to provide, joined up, pro-active care for residents in care homes, those with complex health and social conditions and those requiring multiple services tosupport them in their place of residence.
The post holder will work with care homes, their residents and residents families. The role will also support the wider multidisciplinary team to ensure care is joined up, personalised, andresponsive. The role focuses on proactive case management, coordination ofservices, and navigation of the health and social care system to improvepatient outcomes and reduce health inequalities.
The role will be an integral part of the PCN Team, working in the community across the PCN.
Main duties of the job
Working closely withthe patient and their clinician or other healthcare professionals, the Clinical CareCoordinator will establish and provide
Clinical observations
Patient Care andCase Management
Communication andCollaboration
Service Developmentand Quality
About us
Lincoln Healthcare Partnership (LHP) PCN is made up of two practices (Brayford Medical Practice and Heart of Lincoln Medical Group) based in central Lincoln with a patient population of just under 40,000 people.
Job responsibilities
Work as an integral member of the team caring for patients with complex health and careneeds, including long term conditions and mental health issues.
Undertakeholistic assessments, identifying medical, psychological, and social supportrequirements.
Developand maintain personalised care and support plans in collaboration with clinical teams, patients and families.
Monitorpatients progress, reviewing care plans regularly, and adapting support asneeds change.
Supportpatients to self-manage their conditions where possible, promotingindependence and wellbeing.
Care Coordination
Liaisewith GPs, practice nurses, mental health services, community teams, socialcare, and voluntary sector organisations to ensure integrated care delivery.
Proactivelyidentify patients at high risk of hospital admission or deterioration andcoordinate appropriate interventions.
Facilitatesmooth transitions of care, such as hospital discharge planning and onwardreferrals.
Activelysignpost patients to the correct healthcare professional.
Ensurethat patients have timely access to mental health support, signposting andescalating as necessary.
Assistpatients to access self-managementeducation courses, peer support orinterventions that support them in their health and well-being.
Whereappropriate, to assist patients to access personal health budgets.
Whereappropriate, to support people to access appropriate benefits where eligibleas well as taking up employment and training.
Providecoordination and navigation of patients, and where appropriate their carers,across health and social care services, where appropriate working closelywith social prescribing link workers, occupation therapists and other primarycare professionals.
Attendand participate in the delivery of multi-disciplinary teams MDT withinPCNs.
Whereappropriate, to support people to access appropriate benefits where eligibleas well as taking up employment and training.
Providecoordination and navigation of patients, and where appropriate their carers,across health and social care services, where appropriate working closelywith social prescribing link workers, occupation therapists and other primarycare professionals.
Communication andCollaboration
Workas part of a multidisciplinary team, contributing to regular case reviews andclinical meetings.
Buildstrong relationships with community and voluntary sector partners to enhancepatient support networks.
Advocatefor patients, ensuring their voice is heard and their preferences arerespected.
Provideinformation, advice, and guidance to patients and carers in a clear andaccessible way.
Service Developmentand Quality
Contributeto audits, data collection, and evaluation of the service, identifying areasfor improvement.
Keepaccurate, timely, and up to date records in line with local policies andinformation governance standards.
Generic Responsibilities
Sharebest practice across the PCN.
Beresponsible for the day-to-day planning of personal workloads.
Followdepartmental policies, procedures and guidelines.
Developyourself and the role through participation in training and service redesignactivities.
Contributeto a patient safety culture through reporting and investigation of incidentsand undertaking proactive measures to improve patient safety.
Maintainaccurate clinical records of all patient consultations and related work.
Reviewthe latest guidance ensuring the practice conforms to regulations eg CQC etc.
Supportin the delivery of enhanced services and other service requirements on behalfof the PCN.
Participatein the management of patient complaints when requested to do so and participatein the identification of any necessary learning brought about through clinicalincidents and near-miss events.
Undertakeall mandatory training and induction programmes.
Contributeto and embrace the spectrum of clinical governance.
Attenda formal appraisal with their manager at least every 12 months. Once a performance/training objective hasbeen set, progress will be reviewed on a regular basis so that new objectivescan be agreed.
Contributeto supporting public health campaigns e.g. flu
Supportdelivery of QOF, incentive schemes, QIPP and other quality or costeffectiveness initiatives.
Performother general tasks as assigned.
Maintain professional knowledge, attendingtraining and development as required.
Person Specification
Qualifications
* GCSE A* - C or equivalent in Maths and English
* Experience in care coordination or clinical administration
* Excellent communication skills (written and oral)
* Clear, polite telephone manner
* Competent in the use of Office and Outlook
* Effective time management (planning and organising)
* Ability to work as a team member and autonomously
* Good interpersonal skills
* Problem-solving and analytical skills
* Ability to follow clinical policy and procedure
* Polite and confident
* Flexibility to work outside core office hours
* Driving licence and access to a vehicle
* Flexible and cooperative
* Motivated, forward thinker
* Problem solver with the ability to process information accurately and effectively, interpreting data as required
* High levels of integrity and loyalty
* Sensitive and empathetic in distressing situations
* Ability to work under pressure/in stressful situations
* Able to communicate effectively and understand the needs of the patient
* Commitment to ongoing professional development
* Punctual and committed to supporting the team effort
* Experience of working in a primary care environment
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.
#J-18808-Ljbffr