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PCN Care Coordinator
4 months ago
Job summary
Seeking Care Coordinatorto support the community primary care team to collaborate more effectively andimprove patient care. A key role will be organising and attending regular MDTmeetings with community teams to improve communication and planning for dailypatient care. There is also a requirement to run a larger weekly MDT meetingand ensure planned outcomes are achieved by the team members. This is a PrimaryCare Network (PCN) role supporting the Integrated Neighbourhood team at BanburyCross Health Centre PCN.
Main duties of the job
The Care Coordinator will beresponsible for managing the care of people registered with practices within aparticular PCN. This will involve coordinating the work of healthcareprofessionals and non-clinical staff including volunteers involved in the careof patients registered at GP practices within the wider PCN population.
The postholder will contribute to tackling inequalities in health and social careparticularly regarding individuals with long-term conditions. An ethos ofpromotion of independence and partnership-working is integral to this post.
Akey part of the role of a care coordinator role will be running the daily, smallerMDT meetings as well as the weekly larger group MDT meeting.
These meetings involve theidentification and review or patients recently discharged, at risk ofadmission, or with significant frailty or specific MDT needs, identifiedthrough a variety of means. The Care Coordinator will collate relevantinformation on people requiring an MDT review in addition to providingcoordination, secretarial and administrative support to the MDTs within the INT.
About us
PML is a successful not-for-profit, GP-led organisation providing various NHS community and primary care clinical services to patients across Oxfordshire and Northamptonshire. We have evolved as a NHS healthcare provider since 2004 and in the last few years have grown significantly, now employing around 300 staff with a turnover of circa £16m. PML holds GMS contracts, as well as being a GP Federation representing circa 50 GP practices covering approximately 650,000 patients.
We welcome applicants from a diverse range of backgrounds and circumstances and people with protected characteristics under the Equality Act 2010
Job description
Job responsibilities
Multi-Disciplinary Teams
Overall responsibility for arranging the daily and weekly PCN and Community team led MDT meetings to ensure smooth running of integrated care within the team setting. Key roles include searches and discharge data analysis to identify patients, managing the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members of the meeting as required. Coordinate and manage the administrative functions of MDT meetings. Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function. Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary. Manage reporting required and associated within the DES specifications for required services.Patient Identification
Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required. Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the weekly MDT meetings. Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT. Signpost team members, service users and carers to relevant servicesMaintenance 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 Accurate update and maintenance of GP systems within the MDT. To provide agreed performance/activity data within the MDT and PCN.Communication and collaborative working relationships
Demonstrates ability to work as a member of a team. Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary. Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs. Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations. Work with service users, PCN practices and partners Develop excellent working relationships with all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT Acting as a point of contact for residents, families and professionals who visit the care home, such as MDT members and in-reach specialists. Meet regularly with the clinical lead and review case load and MDT function. Keep the MDT and OHP organisation abreast of good news stories. Provide background information about individuals for the weekly MDT meetings Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public Manage and prioritise workload on a daily basis and deal with the competing demands of the MDTHelping support delivery of PCN services
To support the PCN delivery of relevant services to the patient population including but not limited to the following services: Tackling Neighbourhood Health Inequalities, Personalised Care and Anticipatory Care Undertake basic health care assistant roles such as phlebotomy, simple clinical assessment and support patients as a link worker. Training will be provided to obtain this skill set if needed.Other responsibilities
To act at all times in an anti-discriminatory manner To be able to plan and respond to workload according to operational priorities To support the delivery of these functions across wider locality areas where necessary To undertake any training required in order to maintain competency including mandatory training To contribute to, and work within a safe working environment. The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.Patient Care
Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding Effectively use all methods of communication and be aware of and manage barriers to communication Effectively recognise and manage challenging behaviours, carers and or relatives Provide information to patients, their carers and/or relatives on behalf of the teamSupporting Care Delivery
Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc. Follow through with service users and others involved to ensure all services and care arrangements are in placeAutonomy/Scope within Role
The post holder will be required to work within clearly defined organisational protocols, policies and procedures Person Specification
Skills and Knowledge
Essential
Proven record of excellent written and verbal communication skills and interpersonal skills Evidence of excellent knowledge of Microsoft Office Able to deal with service users sensitively Able to work as part of a team Able to prioritise and manage own workload Excellent motivational and influencing skills Excellent negotiating skills Car user (to travel between more than one GP practice) Excellent interpersonal skills Strong analytical and judgement skills Ability to analyse and interpret information and present results in a clear and concise manner Excellent organisational and administration skills Experience providing advice/signposting to users Able to use NHS Choices website effectively (desirable)
Qualifications
Essential
Is enrolled in, undertaking or qualified from appropriate training as set out by the Personalised Care Institute for Care Coordinators: Diploma/ HNC level (or relevant experience) NVQ Level 3 Business Administration (or relevant experience) Ongoing internal and external training to keep up to date with changes/ developments Long term conditions training (desirable) Welfare Rights basic training (desirable)
Experience
Essential
Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (desirable) Experience in use of databases Experience of administrative duties Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality Working in a multi-disciplinary setting where influence and negotiation is required Knowledge/familiarity with medical terminology Working in a busy and demanding environment whilst delivering in a timely manner Vulnerable adults awareness (desirable) Experience of care of the elderly (desirable) Understanding of current issues facing the NHS (desirable) Knowledge of social services structures Training in continuing care criteria (desirable) Understanding of health and social care processes (desirable)