Care Co-ordinator Moorlands Rural PCN

You will work closely with GP surgery teams, Primary CareNetwork teams, and a range of community health services. Managing your owncaseload, you will deliver effective, coordinated care for vulnerable and frailadults particularly those at risk of emergency hospital admission, A&Eattendances, or out-of-hours care.

You will also play a key role in supportingmulti-disciplinary team (MDT) meetings, with a particular focus on patientsliving in care homes.

Werelooking for a committed, organised, and approachable team player to help usdeliver exceptional care across our Primary Care Network.

Youll work closelywith patients, GPs, and community teams, providing vital support for vulnerableadults and children, often in challenging situations.

Your role will include co-ordinatingcomplex meetings, managing administrative systems, and using IT confidently tocollate and analyse data.

We value excellent communication skills, both writtenand verbal, and the ability to share and receive complex information withclarity and empathy.

Experience in a patient-focused role, particularly withina GP practice or dispensary, is highly desirable.

If you are compassionate,detail-focused, and thrive in a collaborative environment, wed love to hearfrom you.

If you would like to learn more about this role, we warmly welcome an informal discussion. Please contact: Joanne.aldridge2@staffs.nhs.uk

Main duties of the job

Job Description:

• Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
• Support patients to utilise decision aids in preparation for a shared decision-making conversation
• Holistically combine a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP) in line with PCSP best practice based on what matters to the person
• Help people to manage their needs through answering queries, make and manage appointments and ensure that people have good quality written or verbal information to help them make choices about their care
• Support people to take up training and employment and to access appropriate benefits if eligible
• Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing including using the Patient Activation Measure
• Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level
• Explore and assist people to access personal health budgets if appropriate
• Provide coordination and navigation for people and their carers across health and care services working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals
• Support the coordination and delivery of MDTs within the PCN.

About us

Moorlands Rural PCN is a welcoming group of seven practices, caring for around 40,000 people in our community.

Led by two passionate Clinical Directors and a supportive Business Manager, we\’re proud of our friendly, can-do atmosphere.

Our larger multi-disciplinary team includes GPs, nurses, pharmacists, care co-ordinators and more – all working together to make a real difference for our patients.

We\’re forward-thinking, flexible, and happy to consider part-time, or job share roles.

You\’ll find strong peer support, and a team that values your ideas and expertise.

We also work closely with our local GP Federation, helping to strengthen and sustain primary care for the future.

Job responsibilities

Administrative Responsibilities:

• Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN
• Raise awareness within the PCN of shared decision making and decision support tools
• Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations
• To work as a key member of the MDT to help support the development of effective MDT meetings
• Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers
• To ensure that action points identified within the MDT are recorded and followed up
• Under guidance from their line manager, take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team
• To cross reference the patients identified as high risk with the carers register within the practice to support case managers and key workers in developing holistic anticipatory care plans including prevention of carer breakdown
• To work with the wider MDT to identify appropriate case managers for high-risk patients to ensure that patients are reviewed, and anticipatory care plans are developed
• Ensure that all patients Care Plans, diagnostics results, and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available
• To liaise with acute hospitals, cross referencing admission data with the at risk list and coordinating the sharing of key information between the acute hospital teams and the community services
• Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute/community hospital setting

Participate in any training programme implemented by the PCN as part of this employment, such training to include:

Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development

Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

To work in accordance with health and safety policies and procedures including reporting and recording any health and safety incident or accident

Adhere to host employers adult and children safeguarding policies and procedures

This job description is not exhaustive, and duties may vary with the requirements of the PCN

Due to the current Coronavirus (COVID-19) the NHS has had to adjust to new ways of working which may affect initially the way you undertake the job

Person Specification

Qualifications

• NVQ Level 3 or equivalent level of knowledge in office procedures

Experience

• Experience of working under own direction
• Experience in a patient focused environment
• Evidence of experience in wide range of administrative systems and software programmes
• Experience of supporting service improvement
• Previous experience in NHS/Primary Care/Local Authority role
• Experience of planning and organising complex meetings/agendas
• Evidence of working with IT systems
• Evidence of ability to support collation and analysis of data
• Excellent verbal and written skills
• Ability to provide and receive complex information
• Excellent interpersonal skills
• Experience of using a medical software package e.g. SystmOne and EMIS Web
• Proven track record of effective use of networking and influencing skills
• Demonstrable ability to show kindness and compassion
• Demonstrate ability to reflect and learn from situations
• Identifies difficulties as challenges and works with others to identify solutions
• Demonstrates co-operative team working and awareness of the roles of other professionals
• Able to work on own initiative, organising and prioritising own workload to set deadlines
• Ability to adapt and change approach as circumstance dictates
• Persistence and ability to keep going in difficult situations and with complex and uncertain pieces of work
• Understanding of and commitment to equality of opportunity and good working relationships
• An ability to maintain confidentiality and trust
• Can do attitude, able to maintain positivity in the face of adversity
• Good time keeping Flexible approach to work
• Ability to work flexibly across days of the week

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

£25,147 to £27,000 a yearpro rota depending on experience

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