Care Co-ordinator - Horton PCN

We are looking for a highly motivated individual who will work as

part of a multi-disciplinary team to provide expertise across the PCN.

You will ensure patient health and care planning is timely, efficient, and patient-centred. The

role will include responsibilities for the coordination of the patients journey through primary care and secondary

care. You will achieve this by bringing together all the information about a persons identified care and support needs

and exploring options to meet these within a single personalised care and support plan, based on what matters to

the person.

You will be expected to develop links with local GP

practices, colleagues within the service, local communities and VCS to ensure

delivery of integrated, patient focused care, demonstrating flexibility in the

role, and a caring attitude towards patients.

This is an exciting position and you will need to be

self-motivated and able to work on your own, whilst also integrating into a

number of well-established General Practices. You will have excellent

organisational, interpersonal and communication skills together with a good

working knowledge of primary care and the challenges facing patient care in the

NHS.

Job purpose

Our Care Co-ordinator will support the coordination and delivery of MDTs within the PCN by providing extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.

Key role requirements

Support the coordination and delivery of MDTs within the PCN

Overall responsibility for arranging the PCN led MDT meetings and the smooth running of integrated care within the team setting. A key role of the Care Coordinator is to ensure that all new referrals are identified, and information circulated to team members in advance of the meeting.

Take notes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.

Manage reporting required and associated within the NHSE DES specifications for required services.

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care

Receive and collate information from transfers of care plus out of hours calls and present this information to the MDT as required.

Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the MDT meetings.

Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT.

Signpost team members, service users and carers to relevant services.

Support with the administration and patient management of the PCN Enhanced Access Hubs, which provide medical services for patients within our neighbourhood.

To support the Data Quality Manager with administration of the clinical and non-clinical rotas and any associated administrative tasks for the Enhanced Access Service, ensuring all rotas are entered onto the system in advance and ensuring all rota change requests are entered daily.

To contact, rebook and/or task back to practices any appointments cancelled due to unstaffed clinics

To maintain an up-to-date record of compliance for the Enhanced Access workforce, chasing outstanding documentation and bringing any non-compliance to the Data Quality Managers attention.

Support the PCN Manager and Data Quality and Digital Transformation Lead

Support the GP practices and the PCN with completion of targets related to the DES

Develop PCN communications eg newsletters, posters, information leaflets, social media postings

Update and maintain the PCN website to further enhance the patient journey, support the digital agenda, promote usage of digital services and serve as an important notification portal for Practices

To develop a PCN Patient Participation Group (PPG) and work with the GP practices to develop and manage their own PPGs where required

To provide administrative support services with the production of correspondence and documentation.

Be responsible for organising meetings, events, courses and conferences (including hospitality and venue bookings)

Ensure that all activities are monitored and evaluated.

Attend internal meetings as required.

Work in accordance with PCN policies, including the equal opportunities policy and practice.

Attend any training courses and supervision sessions as required.

Work with due regard to the Health and Safety Policies across the PCN, ensuring that all practices and procedures are undertaken in accordance with issued guidelines.

Undertake any other duties as may reasonably be required from time to time.

To be prepared to work flexibly, including evenings and weekends if required.

Care Quality Commission

Work with the general practice teams to ensure the practices are compliant with CQC standards.

Under supervision and support of GPs in practices, the post-holder will strive to maintain quality within the practices, and will:

Participate in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and the Quality and Outcomes Framework.

Alert other team members to concerns about risk, quality and safety.

Participate in investigation of incidents and events as required.

Identify, apply and disseminate research findings relating to PCN practices.

Collect data for audit purposes and use clinical audit to monitor quality in the service and implement change according to findings.

Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.

Work effectively with individuals in other agencies to meet patients needs.

Under the Data Protection Act 2018 (alongside the EU General Data Protection Regulations) the post holder must maintain the confidentiality of information about patients and staff. The work is of a confidential nature and information gained must not be communicated to other persons except in the recognized course of duty. Unauthorised disclosure of confidential information will result in disciplinary action and may lead to your dismissal.

In the course of seeking treatment, patients entrust us with or allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the PCNs practices policies and procedures relating to confidentiality and the protection of personal and sensitive data.

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with the organisations procedures and policies, and current legislation

Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues

Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights

Employees must be aware of the responsibilities placed on them under the Health and Safety at Work Act (1974) to ensure that the agreed procedures are carried out to maintain a safe environment for patients, visitors and staff, including infection prevention and control.

It is the responsibility of all members of staff to provide a high standard of care to patients they are involved with. This includes good infection prevention practice.

All staff have a responsibility to comply with Infection Prevention and Control policies and procedures, this includes:

This is an exciting opportunity to join this GP provider

organisation encompassing GP practices across Bradford City with a total

patient population of around 160,000, and representing one voice for primary

care in the City area. You will be expected to work across a number of

Practices, with a set patient population, alongside both the GP and nursing

staff, to meet the needs of patients by providing direct care using established

guidelines.

Further ongoing support is provided through both local and

countrywide governance and peer support groups. Additional professional

development in line with the individuals needs will be available with

shadowing, e-learning, relevant courses/conferences and higher level training

opportunities being supported.

Qualifications

Essential: - NVQ III In Business and Administration or equivalent knowledge and skills; - GCSE Grade A - C (or equivalent) in Maths and English

Desirable: - Evidence of further study/training

Personal Qualities and Attributes

Experience

Knowledge and Skills

Other