Job summary
We are very excited to be recruiting another Care Coordinator to joinour PCN team. We currently have 6 Care Coordinators and the rest of our PCNstaff include pharmacists, pharmacy technicians, trainee pharmacist,paramedics, Health Care Assistant/Social prescribers (doing home visits andsupport for housebound patients), health and wellbeing coach, occupationaltherapists, physiotherapists, physician associates, admiral (dementia) nurseand nurse associate. We are in theprocess of recruiting 2 Social Prescriber / Link workers.
Main duties of the job
Our CareCoordinators will play an important role within the PCN to reduce healthinequalities and support meeting our PCN and practice targets. They will be working closely with practice and PCN staff to identify, engagewith and proactivelycoordinate personalised care and support planning for the most vulnerablepeople in our community, including the frail/elderly, people living with severemental illness or learning disabilities, and those with long-term healthconditions.
As well asbeing linked with individual practices they will work together as a team witheach Care Coordinator taking a lead for the PCN in a particular area mental health, learning disabilities, frailty and unpaid carers. This willinclude sharing learning and best practise both within the team and across thePCN.
Our CareCoordinators will support Clinical Leads and theMulti-Disciplinary team in the organisation and facilitation of MDT meetings including monthly Care homesmeetings.
To runreports to proactively identify eligible patients and work to increase uptakeof health checks, cancer screening, and other services including self-managementservices. Support with patient engagement, which will include ensuring thatinformation is accessible for all, and having conversations with patients andcarers to increase understanding, alleviate concerns and increase engagementand self-management.
About us
LS25/26 PCN hasa patient population of circa 75,000 across 7 practices:
Garforth Medical Centre
Gibson Lane Practice
Kippax Hall Surgery
Lofthouse Surgery
Moorfield House Surgery
Nova Scotia Medical Centre
Oulton Medical Centre
We are a dynamic, forward thinking PCN team who are passionateabout developing and delivering excellent quality local services to meet theneeds of our patients. Please have a look at our website to find out more aboutour team, projects, services and partners. (
Job description
Job responsibilities
To supportpeople in preparing for or following-up clinical conversations they have withprimary care professionals (including health checks) to enable them to beactively involved in managing their care and supported to make choices that areright for them. You will use knowledge of health and social services availablein the locality, including those offered by the community and voluntary sector,to link people up with these and help them overcome any barriers they mightencounter. The aim is to help people improve their quality of life and avoidunplanned hospital admissions.
Act as acentral 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 personsidentified care and support needs and exploring options to meet these within asingle personalised care and support plan, based on what matters to the person.
KEY RESPONSIBILITIES
Coordinatemultidisciplinary meetings across local care organisations including identifyingpatients in need of review and collating any information required to facilitatetheir review prior to the meeting.
Provideadmin support to multidisciplinary meetings including taking minutes.
UtiliseGP Practice clinical systems (SystmOne) and population health data toproactively identify relevant cohorts of patients to deliver personalised care
Supportpatients within these cohorts to access health checks and other health services
Supportthe PCN in improving overall patient care through promotion of servicesavailable to them locally within the PCN and the wider health system
Liaisewith other key stakeholders as needed for the collective benefit of the patientincluding but not limited to GPs, nurses, pharmacists and other support stafffrom within the PCN practices or from other provider organisations
Assistpatients and carers in managing their own needs, answering their queries andsupporting them to address their needs
Communicateeffectively and sensitively using language appropriate to the patient and theircarer and their level of understanding
Provideaccurate, impartial information, support and guidance to patients and theircarers to enable them to make choices about their care
Raiseawareness of shared decision making and decision support tools, and assistpatients to be more prepared for shared decision making conversations
Toprovide coordination and navigation for patients and their carers across healthand social care services, where appropriate linking with social prescribers andother patient link workers in the PCN
Workin partnership with key providers in the local community to enable improvedaccess to services for patients
Activelyengage with, assist and provide advice to carers, to enable them to sustaintheir caring role escalating any concerns to the practice when required
Workwith practices to support delivery of any national and local targets with regardto the GP contract PCN DES and I&IF
Supportthe PCN in bringing together all of a patients identified care and supportneeds, and explore options to meet these within a single personalised care andsupport plan (PCSP), in line with PCSP best practice, based on what matters tothe patient.
Exploreand assist patients to access personal health budgets where appropriate
Supportpatients to understand their level of knowledge, skills and confidence (theiractivation level) when engaging with their health and wellbeing, includingthrough the use of the Patient Activation Measure
Personal & Professionaldevelopment
Maintaincontinued education by attendance at courses as deemed essential forprofessional development
Participationin annual appraisal review
Maintaininga record of own personal and/or professional development
Governance
Produce complete and accuraterecords of patient consultation, in line with best practice, confidentiality,policies and procedures
Deliver care according to NHSguidance, NICE guidelines and evidence-based care
Take part in the maintenance ofquality governance systems and processes across the PCN and its activities.
Utilise the audit cycle as a meansof evaluating the quality of the work of self and the team, implementingimprovements where required.
Work with other clinical teams onimproving the quality of healthcare in response to local and national policiesand initiatives as appropriate
Evaluate patients response tohealth care provision and the effectiveness of care
Support and participate in sharedlearning across the PCN and wider organisation
Awareness of statutory safeguarding,notification processes and local guidance for children/vulnerablepatients, applying relevant policies and legislation to protect them
Ensurecompliance with policies, procedures and guidelines for self and others, by takingaction or alerting senior management team if the practice appears to contravenepolicy, or if there are concerns over any aspect of patient care.
Health andSafety
Thepost-holder will manage their own and others health & safety and infectioncontrol as defined in the SEL GP Group Health & Safety Policy, the SEL GPGroup Health & Safety Manual, and the SEL GP Group Infection Control Policyand published procedures.
Comply withSEL GP Group health and safety policies by following agreed safe workingprocedures
Awareness andcompliance with national standards of infection control, hygiene, regulatory /contractual / professional requirements, and good practice guidelines.
Correctpersonal use of Personal Protective Equipment (PPE) and ensuring correct use ofPPE by others, advising on appropriate circumstances for use by clinicians,staff and patients.
Reportingincidents using the organisations Incident Reporting System
Confidentiality
Maintain confidentiality of information, acting within the termsof the Data Protection Act and Caldicott guidance on patient confidentiality atall times.
Maintain an awareness of the Freedom of Information Act.
Equalityand Diversity
The post-holder will support, promote and maintain the SEL GPGroup Equality & Diversity Policy.
No person whether they are staff, patient or visitor shouldreceive less favourable treatment because of their gender, ethnic origin, age,disability, sexual orientation, religion etc.
The jobholder must comply with all policies and proceduresdesigned to ensure equality of employment and that services are delivered inways that meet the individual needs of patients and their families.
Other delegated duties
This job description is notintended to be exhaustive - it may be changed after consultation with the postholder. The employee shares with the employer the responsibility for review andmodification of duties.
Person Specification
Qualifications
Essential
1. GCSE grade A-C in Maths and English or skills level 2 in Maths and English or equivalent
Desirable
2. ECDL or other equivalent IT qualification
3. NVQ Level 3 in a health or social care related discipline or equivalent experience
Experience
Essential
4. Relevant experience of working within a similar role, ideally within General Practice
5. Insight into how to evaluate own strengths and development needs, seeking advice where appropriate
6. Experience of providing and receiving complex, sensitive information
Desirable
7. Use of SystmOne
8. Experience of working with people who may face health inequalities living with frailty, people with living with learning disabilities or severe mental illness, and/or carers
Skills and Knowledge
Essential
9. Experience of working in health, social care or other support roles which are in direct contact with people, families or carers
10. Administrative duties including preparing for meetings and writing minutes
11. Has attention to details, able to work accurately, identifying errors quickly and easily
12. Has a planned and organised approach with an ability to priority their own workload to meet strict deadlines
13. Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience
14. An excellent understanding of data protection and confidentiality issues
15. Able to arrange suitable meetings with multiple individuals with often conflicting priorities
16. Self-motivated, pro-active and able to work independently
17. Continued commitment to improve skills and abilities in new areas of work
18. Able to undertake the demands of the post with reasonable adjustment if required
19. Able to access transport to work across the practices within the PCN and attend meetings in other locations
20. Excellent time keeping and prioritisation skills
21. Professional attributes and appearance
22. Excellent IT skills and the ability to run reports and interpret / analyse and present data
Desirable
23. Understanding of medical technology around frailty, population health management and long term conditions
Personal Attributes
Essential
24. Ability to work flexibly to meet PCN demands
25. Committed to personal and team development
26. Excellent interpersonal skills
27. Effective written, verbal and non-verbal communication
28. Flexible & adaptable to change
29. Ability to maintain working relationships with relevant stakeholders and key staff.
30. Excellent organisational and time management skills with
31. the ability to cope with a busy working environment, with periods of interruption throughout the day
Physical Requirements
Essential
32. Commit to a DBS Check
33. The ability to fulfil the travel requirements of post