Care Co-ordinator Team Up Administrator

2 weeks ago

Matlock, United Kingdom Derbyshire Dales Primary Care Network Ltd. Full time

**Care Co-ordinator, Team Up Derbyshire Dales Primary Care Network Ltd.**

**Salary**:£25,147 - £27,596 per annum, pro rata (dependent upon skills and experience)

**Reports to**: PCN**/**Team Up Management Team

**Working Pattern**: Monday to Friday 10am to 6pm with 30 min break

**Location**:Scholes Mill, Old Coach Road, Tansley, DE4 5FY

The post holder may be required to work across the Derbyshire Dales Primary Care Network (PCN) area.

**Leave Entitlement**:27 days per annum plus bank holidays (pro rata)

**Job summary**

Join us at the start of an exciting, new, and challenging healthcare initiative working with Derbyshire Dales PCN Acute Home Visiting Service (AHVS), also known as Team Up. Derbyshire Dales PCN is seeking a dedicated and self-motivated Care Co-ordinator to work alongside and support a multi-disciplinary team, to provide care to our housebound and patients residing in care or residential homes.

This is an exciting opportunity to be at the forefront of the delivery of our new Team Up/Ageing Well model of care. The role will operate across the traditional health and social care organisational boundaries, including with our GP practice partners, Community Rapid Response services and Falls services, ambulance and out of hours services to help clinically deliver the service on a day-to-day basis. The aim for the service is to ultimately provide a holistic approach to acute on day/rapid response services, enhanced health in care homes and enhanced proactive care for older people with frailty and patients with multi-faceted health problems.

**Main duties of the job**

The Care Co-ordinator will be part of the Acute Home Visiting Team (AHVT), who are responsible for managing planned long-term care. The Care Co-ordinators are a pivotal role to the AHVT and will be the interface between service users, families, carers, primary, community and secondary care, social care, mental health, out of hours services and voluntary organisations. You will also contribute to tackling health inequalities in health and social care particularly regarding individuals with long-term conditions and maintain IT based information systems and take responsibility to produce performance data, analyse and report for the service. You will be responsible for co-ordinating, integrating and delivering support to patients, and ensure effective and synchronised care is available to patients, proactively identifying their personalised care needs.

**About us**

Derbyshire Dales Primary Care Network is a group of 7 forward thinking and progressive practices (population circa 50k) who have developed friendly and effective working relationships with each other. The Derbyshire Dales are a great place to live and work. We have a mix of country towns and rural hamlets spread across a large geographic area. Your employer would be Derbyshire Dales Primary Care Network Ltd, and you would be entitled to be part of the NHS pension scheme.

**Key Duties Tasks and Responsibilities**

**Case Work Discussion**
- Overall responsibility for the regular multi-disciplinary team meetings and the smooth running of integrated care within the team setting. The key role of the Care Co-ordinator will be to schedule regular AHVT meetings, manage the meeting agenda items and identifying key themes for discussion, circulating information to the team in advance of the meeting.
- Collate, analyse, and present data and information to the team.
- Co-ordinate and manage the administrative functions of the AHVT meetings.
- Note any key changes and team agreements and actions required and disseminate these to the team.
- Manage the team’s database to track case management, service user journeys and outcomes, and undertake analysis of caseload information for audit, service evaluation, and performance management purposes, to be reported back to the MDT and Team Up Clinical and Operational Leads.

**Patient Identification**
- Receive and collate information from hospital admissions and discharges, plus out of hours calls, ambulance conveyances, and social care, and present this to the AHVT.
- Identify people with complex needs and new service users and present this information to the AHVT.
- Signpost team members, service users, families, and carers to relevant services, referring as appropriate.
- Contribute to assessment to identify a specific need, to maintain independence in the place they call home (own home, residential or care home). Attend visits as appropriate to act as chaperone or to facilitate non-clinical referrals.

**Maintenance of IT based information systems and responsibility for key performance data**
- To ensure the IT requirements for recording activity are adhered to in collaboration with other team members.
- To analyse and provide agreed performance/activity data on behalf of the AHVT for monthly reporting to the Integrated Care Board, and to support ongoing evaluation and success of the service.

**Communication and Relationships**

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