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Ls25/26 Pcn
4 months ago
**Interviews to be held on the 25th March 2024**
This role will be hosted by South East Leeds GP Group, and will be based in the LS25 LS26 Primary Care Network (PCN).
LS25/26 PCN has a 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
Main duties of the job
Our Care Coordinators will play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They will be working closely with practice and PCN staff to identify, engage with and proactively coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, people living with severe mental illness or learning disabilities, and those with long-term health conditions.
Our Care Coordinators will support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings.
To run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, and other services including self-management services. Support with patient engagement, which will include ensuring that information is accessible for all, and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.
About us
We have a team of over 40 staff including pharmacists, pharmacy technicians, trainee pharmacist, paramedics, social prescribers (general and working with young people), Health Care Assistant/social prescribers, health and wellbeing coaches, care coordinators, occupational therapists, physiotherapists, physician associates, admiral (dementia) nurse, nurse associate, Advanced Nurse Practitioner, and a Community Matron. Please see our staffing structure but note that it may be updated as we continue to develop and grow our team.
Our staff sit within 5 teams: Pharmacy, Clinical, Health & Wellbeing, Operational and Frailty, with the aim of supporting our practices and improving the health outcomes for our patients.
In addition, we have built close working relationships with statutory and voluntary sector organisations including Linking Leeds, Primary Care Mental Health team, Memory Support Workers, LCH Neighbourhood teams, Adults & Health, local schools, Garforth NET and Rothwell Live at Home Scheme, libraries, Active Leeds, Local Care Partnership, Community Pharmacy and our care homes.
Job descriptionJob responsibilities
Our Care Coordinators will play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They will be working closely with practice and PCN staff to identify, engage with and proactively coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, people living with severe mental illness or learning disabilities, and those with long-term health conditions.
Our Care Coordinators will support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings.
To run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, and other services including self-management services. Support with patient engagement, which will include ensuring that information is accessible for all, and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.
To support people in preparing for or following-up clinical conversations they have with primary care professionals (including health checks) to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.
To support the frailty and planning ahead service, this will include difficult conversations to people regarding their death and planning for the future.
Act as a central 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 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.
**KEY RESPONSIBILITIES**
Coordinate multidisciplinary meetings across local care organisations including identifying patients in need of review and collating any information required to facilitate
