Primary Care Network Care Coordinator

Care

coordinators provide extra time, capacity and expertise to support patients. You

will work closely with GPs and other primary care professionals within the PCN

to proactively identify and manage a caseload of patients, making sure that

holistic support is made available to them and that their complex needs are

addressed. You may also be asked to contribute towards other administrative

tasks within the practice or PCN.

Key

Responsibilities and Duties

The Care Coordinator will undertake work in line with PCN and

directed priorities. The following are the core responsibilities of the role:

Clinical

Pharmacy Support

Use

clinical system risk stratification tools and Ardens Manger to identify and

call/recall patients for the Clinical Pharmacy Team to review. This includes,

But is not limited to, patients for

Structured

Medication Reviews

QOF

Quality Improvement indicators

QOF

Medicines indicators

IIF

Medicines indicators

Practice

Prescribing Schemes

Audits

Early

Cancer Diagnosis

Support

the delivery of PCN objectives under the Early Cancer Diagnosis requirements of

the PCN DES. This includes but is not limited to:

Attending

Cancer Steering Group meetings

Patient

follow-up from cancer screening

Cancer

care planning

Patient

communications

Enhanced

Care in Care Homes

You

Will

Support

the practice team to identify gaps in existing care plans and help produce and

annual Personalised Care and Support Plan (PCSP), referring to the patients

named GP to complete.

Liaise

with care homes to schedule the monthly Clinical Pharmacist visits.

Liaise

with care homes to ensure new admissions and patients who have been discharged

from hospital, are reviewed at the next Ward Round, and have an updated PCSP.

Cardiovascular

Disease Prevention and Diagnosis

Support

patient call and recall as directed by the Senior Network Manager.

Health

Inequalities

Identify

patient cohorts being targeted by the PCN health inequalities steering group,

inviting them to participate in agreed interventions.

Learning

disabilities care planning.

Supporting

Patients & Social Prescribing

Actively

sign-post patients to a variety of services including Social Prescribing,

making referrals as appropriate.

Utilise

population health intelligence to proactively identify a cohort of patients to

deliver personalised care.

Information

Technology

Write

searches to identify target patient cohorts.

Write

and update templates and protocols to effectively capture relevant clinical and

non-clinical information.

Multi-Disciplinary

Team (MDT) Meetings

Prepare

agendas for MDT meetings and contact all parties to ensure attendance and to

confirm patients to be discussed.

Care

Planning

Support the practice objectives (local and PCN-level) to ensure care plans are actively

created and updated. This includes for learning disability patients, dementia

patients, care home residents and cancer patients.

Identify

patients without recent care plans in place and work with their name GP to

update these plans.

Ensure

that preventative actions are agreed and detailed in care plans to support the

reduction of unnecessary hospital admissions.

Investment

and Impact Fund (IIF)

Support

patient call and recall as directed by the Senior Network Manager.

Ensure

the minimum number of patient contacts by aligning multiple tests and reviews.

Support

Data Collection

Ensure

timely and accurate collation of data for the PCN

Appropriate

management of collected data, ensuring all data is kept and shared in

accordance with all relevant governance requirements.

Validate

and quality assure incoming data.

Run

regular patient searches using clinical systems to have an up-to-date record of

progress of achievement of Key Performance Indicators (KPIs).

Case

finding to support target achievement and enhancing register prevalence.

PCN

Provide

an agreed Care Coordinator service to all PCN practices with duties to be

defined by the PCN managers.

Bolton GP

Federation is a collective vehicle where Boltons GP practices come together to

deliver primary care, providing a place for collaboration, knowledge-sharing

and coordination. The Federation is a voice of the priorities, needs and local

intelligence of primary care into the wider healthcare system.

We are rated

Good by the Care Quality Commission (CQC) and we are proud of the services

that we run, which include Primary Care Networks, Extended Primary Care, and

Experienced Nurse Network and the Covid Vaccination Programme.

Our mission is

to improve health and care. We meet everyday health and care needs for people

by connecting primary care systems and using creative thinking to develop,

improve and support great local services.

Bolton GP

Federation is committed to the Disability Confident Scheme. We guarantee an

interview to disabled applicants who meet the essential criteria for the role and

will provide reasonable adjustments throughout the recruitment process. If

you need adjustments to enable you to apply for this role, please get in touch

with the recruiting manager.

Qualifications

Experience

Skills

Personal Qualities