Care Coordinator

Woodlands Medical Practice is looking to recruit an enthusiastic and reliable individual to join the admin team. The applicant will be able to work under their own initiative and contribute to the overall work of the practice team. Previous experience in a similar role is desirable but not essential, as full training will be given.

The role of a Care Coordinator is to provide extra capacity in primary care and to use expertise in supporting patients to prepare for or follow up on clinical conversations and appointments with primary care professionals through enhanced care navigation and advocacy. The role is pivotal to ensuring all patients receive the best possible care and service.

Key activities include:

• Access to services, advice and information
• Ensuring health and care planning is timely and patient-centred
• Supporting digital initiatives
• Coordinating the patient journey through primary care

The Care Coordinator will work within each practice setting and alongside the MDTs, using their enhanced skills as the first point of contact for patients requiring support and assistance to enable the seamless integration of their care journey through the healthcare systems. The Care Coordinator will have a key role in supporting the delivery of the new Network Contract specifications by working alongside GPs and AHPs.

Main duties of the job include:

• Arranging annual health and wellbeing reviews for patients with learning disabilities and severe mental illness.
• Supporting patients with non-diabetic hypoglycaemia with brief intervention and referral to the NHS national diabetes prevention programme.
• Contacting patients who are eligible for NHS weight management programmes and referring where appropriate to further services.
• Supporting with COVID-19 vaccinations, including coordinating the housebound programme and working in vaccine hubs.
• Calling patients who have not attended cancer screening, to offer appointments and increase cancer screening uptake.
• Supporting practice by contacting patients to invite them for targeted immunisation programmes.
• Supporting practice in delivering a long-term condition model of care.
• Supporting patients in conversations regarding urgent care plans.
• Supporting patients with cancer and coordinating care reviews.

The post holder will be expected to carry out work duties and tasks in accordance with all relevant codes of practice. This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position.

About us:

Woodlands Medical Practice is located in East Finchley. We are a training Practice working with training GPs and medical students. We are high QOF achievers and part of PCN2, which is a large innovative PCN. Our doctors, nurses and all other staff are dedicated to offering a professional service. We are a friendly surgery committed to delivering excellent care to our patients and a positive working environment for our staff.

Job responsibilities include:

• Work with GPs and other primary care professionals to identify and manage a caseload of patients.
• Coordination of care for patients across health, social care and mental health as appropriate.
• Facilitating the smooth and planned discharge and handover between care settings.
• Identify and work with a list of named patients to encourage independence and improve the quality of care.
• Provide feedback to the practices, troubleshoot and escalate actions as necessary.

Key duties and responsibilities:

• Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans.
• Support patients to use decision aids and create single personalised care and support plans.
• Explain the management of a patient's pathway to clinical staff.
• Work closely with all relevant care agencies to ensure a coordinated patient care plan.
• Ensure that a proper handover of care between different settings has taken place.
• Collect data on patients/carers and ensure all patient notes are updated.
• Use healthcare technologies to optimise service delivery.
• Organise and attend relevant meetings when required.
• Network and develop strong relationships with local NHS players.
• Be a contact point for GPs/practices and establish systems for timely responses to queries.
• Help people manage their needs and support them in making appointments.
• Raise awareness of shared decision making and assist people in having these conversations.
• Assist patients in streamlining their own care and onboarding to new technology.
• Coordinate and manage the Patient Participation Groups.
• Capture patient positive experiences and feedback.
• Maintain a good working knowledge of health and safety procedures.
• Participate in regular appraisals and practice reviews.
• Work flexibly to meet the needs of patients.
• Undertake any other duties appropriate to the grade and purpose of the job.

Person Specification:

Qualifications:

• Relevant degree or equivalent level of training and experience.
• Evidence of consistent pattern of learning or working within similar sectors.
• Qualification in health or social care allied profession.

Experience:

• Good phone and written communication.
• Managing multiple patients or cases at once.
• Knowledge of the needs of vulnerable adults and safeguarding.
• Understanding of basic health and social care terminology.
• Good interpersonal skills and ability to communicate confidently with staff.
• Ability to work well across teams and manage time effectively.
• IT skills and experience in the use of Microsoft Excel.
• Experience of working in primary care and GP practice.

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and will require a submission for Disclosure to the Disclosure and Barring Service.