About this role
Job summary
You will work with GP practice teams to coordinate the care of patients with frailty, cancer, long term conditions, safeguarding and social issues, patients requiring proactive care, and patients who require support to communicate effectively. You will liaise with the patient, practice team, secondary care teams, social services, the voluntary and community sector, and other members of the Primary Care Network team to help smooth the patients pathway, expedite care where appropriate, and follow up letters and results.
Main duties of the job
You will support the practice to deliver good quality care for frail patients, patients in palliative care, and patients with long term conditions. You will work with the practice team to prepare for effective GSF and frailty meetings and ensure that processes such as falls assessments and medication reviews are carried out in a timely manner. Care Home patients and Flu/covid and RSV vaccine delivery. Where appropriate, you will help develop a personalised care and support plan for these patients. You will support the practice to ensure that patients are reviewed at an appropriate frequency, and to achieve QOF, IIF, LIS & DES targets.
You will be working as part of the Redcar Coastal PCN team to support the patients of 7 GP practices.
About us
We are a well established forward thinking GMS practice comprising 5 GP partners, 1 Advanced Nurse Practitioner Partner, 3 Practice Nurses, 1 Phlebotomist and 1 HCAs supported by an excellent reception/admin team.
We also have attached staff such as FCP, AMHN, Registrar's, as well as student GPs i training
We are a SystmOne practice.
Job description Job responsibilities
JOB DESCRIPTION
PRACTICE: Zetland Medical Practice
LOCATION: Windy Hill Lane Marske and any other location requested by the practice
HOURS OF WORK: 35 hours over 4 days - although this is flexible (30 min unpaid lunch and 2 x 15 min paid breaks) and staff may when appropriate be expected to work outside those hours or at weekends if opening times at the practice change.
Service Delivery
Work with practice teams to coordinate care for patients with greater needs, to improve the patient pathway and expedite care as appropriate
Proactively identify patients who require care coordination, using agreed criteria and population health tools as appropriate
Support the delivery of the practice GSF and frailty programmes
Support the achievement of practice quality standards including QOF, IIF, DES and LIS.
Work closely and in partnership with the Social Prescribing Link Workers, to address wider determinants of health, such as poor housing, debt, stress and loneliness and identify and prioritise a person's care/support needs in a single personalised care and support plan, based on what matters to the person in shared decision making process.
Help patients manage their needs through answering queries, making and managing appointments, and ensuring that people have access to good quality information about their care
Assist people to access personal health budgets where appropriate
Coordinate appointments and encourage uptake of vaccinations in eligible populations
Encouraging uptake of QOF LTC Annual and Structured Medication Reviews
Encouraging the delivery of good quality annual health checks for patients with learning disabilities and SMI.
Supporting the practice in delivering its IIF priorities
Supporting cancer screening, including FIT tests/bowel screening, cervical screening, and breast screening. Refer smokers to smoking cessation.
Coordinating and following up of referrals and appointments.
Any other tasks required by the management team.
Specific Tasks/ Responsibilities/Communication
Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment
Support patients to use decision aids in preparation for shared decision-making conversations
Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating
Anticipate barriers to communication and take action to improve communication
Maintain effective communication within the PCN and with external stakeholders
Delivering a quality serviceProduce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures
Prioritise, organise and manage own workload in a manner that maintains and promotes quality
Deliver care according to NSF, NICE guidelines and evidence-based care
Assess effectiveness of care delivery through self and peer review, and clinical supervision
Partake in the audit cycle as a means of evaluating the quality of the work of self and the team
In partnership with other clinical teams, collaborate on improving the quality of health care responding to local and national policies and initiatives as appropriate
Evaluate patients response to health care provision and the effectiveness of care
Participate in shared learning across the organisation
Actively participate in network/practice significant event procedures and work in accordance with revised protocols and procedures.
Understand and apply legal issues that support the identification of vulnerable and abused children and adults, and be aware of statutory child/vulnerable patients health procedures and local guidance
Team workingUnderstand own role and scope and identify how this may develop over time
Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working
Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence
Prioritise own workload
Work effectively with others to clearly define values, direction and policies impacting upon care delivery
Discuss, highlight and work with the team to create opportunities to improve patient care
Learning and development Enrol in and successfully undertake training set out by the Personalised Care Institute as part of job role. Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments eg courses and conferences.
Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments eg courses and conferences.
General Responsibilities
Ensure strict confidentiality of correspondence, reports, meetings and verbal communications as appropriate.
Adapt to and support any changes that are implemented to improve the service.
At all times provide a caring service and to treat those with whom they come into contact in a courteous and respectful manner.
Demonstrate commitment by the efficient completion of all tasks allocated.
Carry out duties and responsibilities in compliance with health and safety policy and statutory regulations.
Adhere to equal opportunities policy throughout the course of employment.
Equality and Diversity
Identify patterns of discrimination and take action to overcome this and promote diversity and equality of opportunity
Enable others to promote equality and diversity in a non-discriminatory culture
Support people who need assistance in exercising their rights
Monitor and evaluate adherence to local chaperoning policies
Act as a role model in the observance of equality and diversity good practice
Accept the rights of individuals to choose their care providers, participate in care and refuse care
Person Specification
Experience Essential
Minimum of 2 years' experience of working with Health Care or Social care professionals and or previous experience in the NHS or social care or relevant. Experience of providing and receiving complex, sensitive and confidential information. Able to deliver successful outcomes within determined timeframes. Experience of working with GP clinical systems, such as SystmONe/EMIS. Positive attitude to work, colleagues and patients.
Desirable
Experience of working in general practice. Non-judgemental attitude to patients.
Qualifications Essential
Knowledge and Qualifications GCSE Grade A C in Maths & English or functional skills level 2 Maths or English. Understanding of health and social care processes. Understanding of the current issues facing the NHS. Driving License. A good level of knowledge and understanding of the health needs of patients in the area.
Desirable
Knowledge and Qualifications Qualification in Health and Social Care or allied professional. Willingness to travel between GP practices and work from various locations in the area.
Skills Essential
IT skills including accurate written/electronic records and documents. Excellent organisational skills and ability to prioritise tasks effectively. Be self-motivated and use initiative. Able to work under pressure. Empathy with the patient's needs and conditions. Discretion in the handling of sensitive and confidential information. Excellent oral and written communication skills; able to engage effectively with a wide range of audiences.
ADDITIONAL REQUIREMENTS Essential
Commitment to continuing professional development of self and others. Able to maintain the consistent delivery of high-quality services. Satisfactory completion of an enhanced check through the disclosure and barring service. Legal right to work in the UK. A commitment to anti-discriminatory practices in employment, training and service delivery. An understanding of Health and Safety responsibilities. Flexibility in working hours. Excellent Attendance Record.
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.
Employer details Employer name ZETLAND MEDICAL PRACTICE
Address Windy Hill Lane
Marske-by-the-sea
Redcar
Cleveland
TS11 7BL
United Kingdom
Employer's website https://www.zetlandmedicalpractice.co.uk (Opens in a new tab)