QOF Care Coordinator

3 days ago

Bristol BS HA, United Kingdom Tyntesfield Medical Group Full time

Co-ordinate care for disease prevention and actively promote attendance at Health Promotion clinics Have a good understanding of QOF targets and ensure patients are called for review in a timely manner Regularly search for patients with poor disease control and target them for additional support, e.g., for weight loss/drug compliance/overdue blood tests or other investigations Actively search for patients with a high BMI or smokers to support to change Refer signpost patients to smoking cessation, exercise and weight loss services Liaise with the Social Prescribing Team (Wellbeing Team) when required Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care Help patients to manage their needs through answering queries, making and managing appointments Work with the GPs and other primary care professionals to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals Discuss patient related concerns with a GP where required Support pre-diabetic patients to ensure annual HbA1c and referral to National Diabetes Prevention Programme education where necessary To improve the Population Health Management within the practice to enable better clinical outcomes Ensure the health promotion clinics are used efficiently and effectively by actively managing clinic bookings and patient recall. The support would include: Ensure early follow up for diabetic review if needed more frequently than annually Ensure the patient has the most efficient appointment if they have co-morbidities to improve engagement and compliance Invite patients on the Learning Disability register for the first part of their annual review with the QOF Team and book the second part Send reminders to patients overdue their cancer screening (breast, bowel, cervical, PSA) Coordinate long term condition monitoring for housebound patients Create and edit EMIS searches Claim on behalf of practice: CQRS, Local Enhanced Services, Public Health, PPA prescriptions

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