Primary Care Coordinator

3 months ago

Haywards Heath, United Kingdom Alliance for Better Care CIC Full time

Job summary

This role is tosupport the smooth co-ordination of patient care for one practice within thePrimary Care Network for the benefit of our patients.

The CareCoordinator will be responsible for consulting with patients and determiningtheir needs, developing care plans, coordinating patient-care services,educating them about their condition, empowering them to be independentwhenever possible and working with the care team to evaluate interventions.

Main duties of the job

To work at one base within a Primary Care Network. To support adultpatients and assist them through the healthcare system by acting as a patientadvocate and navigator, empowering them and educating them to promote andsupport their independence. To support adultpatients and assist them through the healthcare system by acting as a patientadvocate and navigator, empowering them and educating them to promote andsupport their independence. To talk topatients, and where appropriate their families and/or carers, on the practicepremises, remotely by telephone or video, or in the patients home if needed. Liaise with CareHomes as necessary.

About us

Alliance for Better Care CIC is a GP Federationthat unites 47 NHS GP practices across 12 Primary Care Networks in Sussex andSurrey. We support our Primary Care colleagues as well as their patients, totransform how healthcare is managed within the community.

As a membership organisation, our focus is to work in partnership with ourmembers and help them to improve the provision of General Practices in thelocal area.

We work with and listen to our GP Practices, PCNs, Hospitals, CommunityOrganisations and the Third Sector. These vital partnerships ensure that,together, we deliver a truly integrated approach that offers the support andexpertise needed to effectively serve our communities.

Haywards Heath Central Primary Care Network is a NHSCollaboration between two GP Practices Dolphins Practice and Newtons Practice- working together to provide enhanced access services.

Our surgery teams work closely, sharing expertise andresources to develop new services. Our vision is to continue to improve thequality of care that we provide in alignment with the needs of our patientpopulation.

Our PCN builds on the existing primary careservices and enables a greater provision of proactive, personalised and moreintegrated health and social care. We are supported by practitioners inadditional roles who allow us to create bespoke multi-disciplinary teams basedon the needs of our local population.

Job description

Job responsibilities

MDTCoordination

Overallresponsibility for arranging MDT meetings and the smooth running of integratedcare within the medical centre. A key role of the Care Coordinator will be toschedule the MDT meetings and manage the meeting agenda items, ensuring thatall new referrals are identified, and information is circulated to team membersin advance of the meeting. Identify patientsto discuss at PCN level MDTs with a view to reducing unplanned admissions andexacerbation of conditions.

Managinga caseload

Identify patientsthat may need support by receiving information about transfers of care(including hospital admissions and discharges) and from internal practiceintelligence. Educate patients(and if applicable and if appropriate consent is in place, their carers orfamily) about their condition and medication, and give them specificinstructions. Help patientsunderstand their condition by liaising with clinical colleagues, especially thepractice pharmacy team, regarding their medication. Aim for patients to havespecific instructions regarding their medication and understand how they accessrepeat prescriptions and reviews. With the help ofrelevant clinical colleagues, develop a care plan to address patients personalhealth care needs. Ensure care plans are maintained, updated, and uploaded toall relevant systems for sharing with other providers, including SystmOne andShareMyCare. Promote clearcommunication amongst a care team and treating clinicians by ensuring awarenessregarding patient care plans. Assist and empowerthe patient to consult and collaborate with other health care providers andspecialists to set up patient appointments and treatment plans. Check in on thepatient regularly and evaluate and document their progress.

Linking with other services

Signpost teammembers, service users and carers to relevant services including the PCN SocialPrescribing Link Worker Service. Liaise with the Social Prescriber and MentalHealth Support Coordinator regarding patients that are identified as needingwell-being support. Liaise with practice clinicians responsiblefor frailty regarding patients that are identified as needing ongoing support. Liaise with acute trusts, care homes,hospices, community and social care providers as required.

RecordKeeping

Keep accurate andup-to-date records of contact with patients, carers and professionals,including use of SystmOne to record patient contact on the medical record. Use accurate SNOMED codes to record patientcontacts and interventions, mainly via the use of provided templates, for auditpurposes and monitoring and measuring outcomes. Manage reporting required and associatedwithin the DES specifications for required services. Report case studies and outcomes to the PCN ona quarterly basis.

GeneralResponsibilities

Work as part of theteam to seek feedback, continually improve the service and contribute tobusiness planning. Undertake any tasksconsistent with the level of the post and the scope of the role, ensuring thatwork is delivered in a timely and effective manner. Attend ongoingtraining and courses to keep abreast of new developments in health care. Treat patients withempathy and respect and conduct oneself in a professional manner. Attend andcontribute to relevant meetings. Duties may varyfrom time to time, without changing the general character of the post or thelevel of responsibility.

Please see the full job description for further information.

Person Specification

Knowledge & Experience

Essential

Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety

Desirable

Experience of working directly in either the NHS or Adult Social Care

Qualifications

Essential

Demonstrable commitment to professional and personal development with a can do attitude.

Desirable

NVQ Level 3, Advanced level or equivalent qualifications or working towards Training in motivational coaching and interviewing or equivalent experience

Behaviours & Values

Essential

Able to work flexibly and enthusiastically within a team or on own initiative

Skills & Abilities

Essential

Able to listen, empathise with people and provide person- centred support in a non-judgemental way Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity Committed to reducing health inequalities and proactively working to reach people from all communities Able to support people in a way that inspires trust and confidence, motivating others to reach their potential Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders Able to identify risk and assess/manage risk when working with individuals Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role when there is a mental health need requiring a qualified practitioner Able to provide leadership and to finish work tasks Able to maintain effective working relationships and to promote collaborative practice with all colleagues Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues Demonstrates personal accountability, emotional resilience and works well under pressure Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines High level of written and oral communication skills

Desirable

Excellent IT skills including Excel as well as knowledge of GP clinical systems, experience of data entry and coding

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