You will be responsible for coordinating, integrating and delivering support to practice patients. You will work with colleagues, patients, their families and carers, to improve their health and wellbeing by navigating them to the appropriate services. Ensure they have good quality information to support their decision making.
You will guide them to access these services and any appropriate funding that is available to support them, including access personal health budgets where appropriate.
All aspects of project work and working with Neighborhood Health Projects, the projects may be targeted at specific patient groups, identified by GP practices. These patients will include but are not limited to adults with complex long term health needs, depression, organic mental illness, and those who are at risk of social isolation.
You will work collaboratively with the general practice teams, including social prescribing link workers, to meet the needs of patients and to support the delivery of the Primary Care Network responsibilities and objectives.
You will work collaboratively with the general practice teams, to meet the needs of patients and to support the delivery of the Primary Care Network responsibilities and objectives.
Main duties of the job
You will work closely with the PCN Manager and the PCN team, patients, families and carers, to improve their health and wellbeing by navigating them to the appropriate services. Ensure they have good quality information to support their decision making, take a holistic approach, bringing together all of their identified care and support requirements into a single personalised plan based on what matters most to the patient. This could include access to peer support or interventions that assist them in their health and wellbeing as well as supporting patients.This is done using a single point of access system and working closely with the practices and care homes.You will bring together the patients identified care and support needs and explore with them, their options to meet these into a single personalised care and support plan (PCSP).
All aspects of project work will need to be undertaken including Neighborhood Health Projects, this service may be targeted at specific patient groups, identified by GP practices. These patients will include but are not limited to adults with complex long term health needs, depression, organic mental illness, and those who are at risk of social isolation.
You will be involved in daily data entry, rota planning and administration to ensure the clinical systems and are all up to date.
You will be asked to cover Enhanced Access to support the practices with clerical issues and work, this will include some evening and Saturday morning work.
About us
CygnetPCN covers a large geographical area within the East Riding of Yorkshire. Ournetwork covers over 51,000 patients and is made up of the five following GPPractices:
Bartholomew Medical Group
Snaith & Rawcliffe Medical Group
Montague Medical Practice
Howden Medical Centre
Ournetwork comprises of a range of roles from Clinical Director to CareCo-ordinator.
PCN's build on existing primary care services and enable greaterprovision of proactive, personalised, coordinated and more integrated healthand social care for people close to home. Our PCN are proactively providingcare and services for the people and communities we serve.
Newroles are being introduced to the network as we are expanding into differentareas of Healthcare.
Thenetwork provides a single point of access for the nursing, residential andlearning disability homes in the area.
Allour team are passionate and committed to making a difference to patient care.
Job responsibilities
* Working towards achievement of PCN directedpriorities (e.g. Coordination of system widecare within our local Care Homes and other aspects of Primary Care asnecessary).
* Proactively identify and work with cohorts of patients to coordinate and navigate the support necessary for their personalisedcare requirements
* Work on PCN wide projects to tackle healthinequalities through the Neighborhood Health Partnership
* Ensure that patients have good qualityinformation to help them make informed choices about their care
* Ensure regular and consistent communicationwith the patient, referrer and wider care system regarding patient progress andany complications or guidance
* Coordinate and support PCN training days and work closely with the PCN Manager
* Within the scope of PCN priority areas data entry is crucial, you will monitor data to ensure tasks are completed and care delivered in line withnational timelines.
* Liaise with multi agencies to coordinatepathways of care for patients across local services, colleagues and the practices.
* Support Quality and Outcome Frameworks (QoF)and other National and Local targets of best practice.
* Work within all policies and proceduresensuring that individual's and carers' information remains confidential
* Provide accurate and timely performancereporting within the agreed framework
* Maintain and develop engagement with allpractice staff and encourage best practice
* Rota planning and entry into the clinical systems
* Support Enhanced Access for the practices, this will include some evejnings and Saturday morning work.
Person Specification
Other
* Meets DBS reference standards and has a clear criminal record, in line with the law on spent conviction
* Access to own transport and ability to travel across the locality on a regular basis
* Continued commitment to improve skills and ability in new areas of work
* A good sense of humour
Qualifications
* GCSE Grade C or above in Maths and English, or equivalent qualification.
* Qualification in a health or social care allied profession
Experience
* Experience of supporting people, their families and carers in a related role (including unpaid work)
* Demonstrable experience of effective planning and organisational skills to deliver targets to deadlines
* Experience of data collection and providing monitoring information to assess the impact of services
* Working in a multi-disciplinary setting where influence and negotiation is required
* Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work)
* Experience of working with people with diverse health and social care needs
* Experience of multi-agency working and signposting to appropriate support
* Knowledge/familiarity with medical terminology
* Understanding of Population Health
* Knowledge of Care Plans
Knowledge/ Skills
* Excellent verbal communication skills with the ability to communicate effectively at all levels with patients and carers, specialist services, GPs and colleagues
* Listening skills & displaying empathy
* IT literate with good understanding and skills of all Microsoft Applications and as well as the ability to understand and adopt other software platforms
* Creative, flexible and imaginative approach to working with people with diverse support needs
* Understanding of and barriers people face to accessing services and how to overcome them
* Ability to support and motivate people to make sustained changes in their lives across all ages
* Able to work independently & prioritise own workload
* Ability to reflect on and share practice with peers
* Experience using SystmOne/ Emis clinical system
* Knowledge of a range of community groups and services which support wellbeing
* Knowledge of the safeguarding interventions and awareness of the Mental Capacity Act
* Awareness of data protection and confidentiality issues
* Knowledge of a range of interventions which support behavioural change e.g., Motivational Interviewing
* A knowledge of Primary Care/Community Care or the Voluntary sector
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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