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PCN Care Co-ordinator

3 months ago

Milton Keynes, United Kingdom Asplands Medical Centre Full time

Job summary

We have an exciting opportunityfor a passionate and dedicated Care-Coordinator to join our team for a fixedterm contract of 9 months to cover maternity leave and newly commenced researchwork led by our Occupational Therapist. You'll be based within the AscentPrimary Care Network, formed by 3 GP practices (Asplands Medical Centre, WalnutTree Health Centre, Fishermead Medical Centre), at the Asplands Medical Centresite in Woburn Sands.The successful applicant will be placed within our supportive and proactive,friendly team. You will be working together to deliver the PCN's keypriorities: identifying patient's withunmet clinical and care needs andorganising their onward appointments, gathering data for clinicians andmanagement staff, recruiting patients to our proactive care initiatives,coordinating group education sessions with our specialist clinicians, conductingpatient and carers routine care reviews, supporting the organisation of theCOVID vaccination service and more.

The successful candidate willhave care coordinator training already, excellent interpersonal communicationskills, be organised, proactive, patient and empathetic.

The role is to cover 25 hours aweek and our service operates Monday to Friday, with flexibility of hoursbetween 8am - , with possible occasional Saturday working.

We look forward to hearing fromyou

Main duties of the job

As a Care Coordinator, you will:

Proactivelyidentify and support individuals, including the frail, elderly, and those withlong-term conditions, providing co-ordination and appointment navigationfor patients and their carers, including assisting in the co-ordination of the PCN immunisation programme this winter. Conduct IT system searches andcommunication with clinicians and our multidisciplinary team. Workspecifically with our Occupational Therapist on the PCN Frailty Project,coordinating recruitment and distribution and collection of surveys andactioning responses. Be organised, patient, empathetic andable to reprioritise tasks at short notice. Use SystmOne on adaily basis with confidence to run searches and keep care recordsup-to-date,including identifying patients with long-term healthconditions and those requiring medication and disease monitoring andcommunicating with them to arrange recall and monitoring appointments. Help patients to manage their needs through answeringqueries, making and managing appointments. Identify those who may benefit from proactive care and support for health conditions, assisting them in seeking appropriate interventions as well as co-ordinating group interventions with the MDT. Conduct follow-ups on communications from outpatient in-patienthospital services. Contributing to audits and data collection to aid evaluations of the PCN services will be needed.

About us

We have a friendly and helpful team across the Network and benefit from well-integrated site support from the Asplands Medical Centre team for this co-ordinator role. You'll get to work closely with our Occupational Therapist and the Social Prescribing and Mental Health and Coaching teams. We also have Physiotherapy, Pharmacy and Nursing representation within our close PCN team. The role is interlinked with the Practice team at Asplands where the keen clinicians and administrative teams all work positively together to get the best for their patients.

Job description

Job responsibilities

Therole exists to support the delivery of the high quality primary healthcare andthe Primary Care Network agenda. We are committed to delivering the localcommissioners vision of Start Well, Live Well, Age Well and you will supportthe delivery of a number of the Primary Network key care priorities byproactively searching for patients with unmet clinical and care needs andorganising their onward appointments, gathering data for clinicians andmanagement staff, recruiting patients to our proactive care initiatives, coordinatinggroup education sessions with our specialist clinicians, conducting patient andcarers routine care reviews, supporting the organisation of the COVIDvaccination service and much more.

Therole supports a variety of services such as mental health, social prescribing,pharmacy, physiotherapy, occupational therapy, vaccination, care homes andenhanced access services.

Thesuccessful candidate will have excellent interpersonal and communicationskills, be organised, proactive, patient and empathetic.

AtAscent PCN we offer a friendly, supportive working environment and demonstratea commitment to providing professional development and supervision for allstaff, together with a competitive salary package and company pension.

Thereis also the opportunity for local links to be established with other PCNs tosupport professional supervision and enable the sharing of innovation and bestpractice through peer support.

Duties:

Theduties of this post are a guide to the range of responsibilities that may berequired. These may change from time to time to meet the needs of the serviceand/or the development needs of the post holder.

Asa Care Coordinator, you will:

Proactivelyidentify and support individuals, including the frail, elderly, and those withlong-term conditions.

Provideco-ordination and appointment navigation for people and their carers acrosshealth and care services, working closely with social prescribing link workers,other primary care professionals and health and social care colleagues; helpingto ensure patients receive a joined-up service and the most appropriatesupport.

Collaboratewith clinical and non-clinical teams to ensure people receive the support theyneed in a timely manner, using IT search and report systems.

Empowerpatients to manage their conditions and access necessary services, enhancingtheir quality of life.

Workalongside PCN and practice clinical staff for a comprehensive approach topersonalised care.

Workalongside the Occupational Therapist on the PCN Frailty project, coordinatingrecruitment and distribution and collection of surveys and actioning responses.

Engagewith diverse populations from various cultural and social backgrounds.

Behighly motivated, forward-thinking, an excellent communicator with stronginterpersonal skills. You need to be organised, patient, empathetic and able toreprioritise tasks at short notice.

Beexperienced in health, social care, or support roles involving direct contactwith people, families, or carers.

UseSystmOne with confidence to run searches and keep care records up-to-date byidentifying and updating missing or out-of-date information about theindividuals circumstances.

UseIT database systems to identify patients with unmet care needs.

Helppeople to manage their needs through answering queries, making and managingappointments, and ensuring that people have good quality written or verbalinformation to help them make choices about their care.

Workcollaboratively with GPs and other primary care professionals within the PCN toproactively manage an ever-changing caseload, which may include patients withlong-term health conditions and those requiring medication and diseasemonitoring search and recall patients for blood tests and reviews.

Workwith the Network Practices to help co-ordinate the roll out of the winter CovidVaccination programme

Supportthe coordination and delivery of multidisciplinary team education groups ( nutritiongroups, mental health groups) and attend team meetings with the PCN

Supportthe PCN in developing communication channels between GPs, people and theirfamilies and carers and other agencies

Identifyunpaid carers and help them access services to support them

Identifythose requiring additional support for health-seeking behaviours and assistthem in identifying appropriate interventions.

Conductfollow-ups on communications from outpatient in-patient hospital services.

Maintainrecords of referrals and interventions to enable monitoring and evaluation ofthe service.

Contributeto risk and impact assessments, audits, monitoring and evaluations of theservice.

Person Specification

Skills

Essential

Confident and empathetic communicator Excellent organisational skills Attention to detail and accuracy

Desirable

Developing and using searches within SystmOne clinical system. Proficient in the use of Microsoft Office products Ability to self-direct tasks, use own initiative, to meet an overall goal

Qualifications

Essential

Qualified from appropriate training course as set out by the Personalised Care Institute for Care Co-ordinators or NVQ Level 3 in Adult Care or NVQ Level 3 in Business Administration

Desirable

Additional Qualification in health or social care allied profession Long term conditions and welfare rights basic training

Experience

Essential

Working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity). Experience of data collection and using tools to measure the impact of services Experience of working within multi-professional team environments Experience or training in personalised care and support planning.

Desirable

Working with elderly or vulnerable people Experience of healthcare and complying with best practice and relevant legislation Supporting people, their families and carers in a related role Minimum of 1 year experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field