About this role
Job summary
Morley and District Primary Care Network have an exciting opportunity for an experienced care co-ordinator to join their team. The Care Coordinator will work within their expertise as part of a multi-disciplinary team to provide expertise in developing robust IT systems and information management across several Practices to help implement efficient services, maximise income and produce quality reporting.
This role is intended to become an integral part of the PCNs multidisciplinary team.
This is an important role that will help shape and form the layout of Neighbourhood health and Proactive Care in Morley, Leeds.
The suitable candidate should be passionate about making a difference in primary care and enjoy working as part of a multi-disciplinary team across services.
Proactive Care co-ordinators play an important role within a PCN to proactively identify and work with patients, including those with frailty and with long-term conditions, to provide co-ordination and navigation of care and support services across health and care organisations across the community.
They work closely with GPs and practice teams to manage caseloads of patients, acting as a central point of contact to ensure appropriate support is made available to patients and their carers; liaising with patients to form more personalised care plans, supporting them to understand and manage their condition and ensuring their changing needs are addressed.
This is achieved by collating all information about a patients identified current clinical and non-clinical care and further non-clinical support needs exploring options to meet these within a single personalised care and support plan, based on what matters to the patient ready for clinical triage.
Care co-ordinators will provide time, capacity and expertise to support patients in preparing for, or following-up, clinical conversations. Enabling them to be more actively involved in managing their care and supporting them to make choices that are right for them.
Main duties of the job
We are looking for a proactive care coordinator to work on our Neighbourhood Health and Proactive Care targets within population health management, focusing on patients with Frailty and Long-Term Conditions.
This will involve working with data, reporting, information gathering, data analysis, supporting the team with relevant and timely data streams and organising MDTs for all stakeholders involved in patient care, providing data required and ensuring the organisation and evaluation minutes when required of all meetings held. It will also involve engaging with patients, information assessing and evaluating, and may involve being in the community talking to patients face to face to support managing their care and referring within the PCN Integrated Proactive Care Team.
Key responsibilities
Coding and reporting data from practice systems, data analysis, cross referencing data streams and delivering data for team members.
Reviewing patient records and collating information for caseloads in preparation for clinical triage.
Engaging with patients, their families and carers, to improve their understanding of their condition.
Supporting patients to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Work with patients, their families, carers and healthcare team members to encourage effective proactive behaviours to avoid reactive care crisis points.
Support PCNs in developing communication channels between GPs, patients, their families, carers and other stakeholder agencies.
Help patients to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
Provide co-ordination and navigation for patients and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.
Work collaboratively with GP practices, other primary and secondary care professionals, other community stakeholders and the PCN to proactively identify and manage a caseload, which include patients with frailty and long-term health conditions where appropriate.
Enable access to personalised care and support
Take referrals or proactively identify patients who could benefit from support through care co-ordination.
Have positive, empathetic and responsive conversations with patients and their families and carer(s), about their needs.
Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance.
Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable patients to access support and services that are right for them.
Use tools to measure patient levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.
Support patients to develop and implement personalised care and support plans.
Review and update personalised care and support plans at regular intervals.
Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
Co-ordinate and integrate care
Make and manage appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
Help patients transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system.
Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.
Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a co-ordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
Actively participate in multidisciplinary team meetings in the PCN.
Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
Record what interventions are used to support patients, and how patients are developing on their health and care journey by providing evaluations.
Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
Work sensitively with patients, their families, and carers to capture key information, while tracking of the impact of care co-ordination on their health and wellbeing.
Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
3. Supervision/professional development
Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required.
Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Access relevant GPs to discuss patient related concerns, and be supported to follow appropriate safeguarding procedures
Miscellaneous
Establish strong working relationships with GPs and practice teams and PCN clinical team members working collaboratively with other care organisations and stakeholders, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting daily as a team MDT.
Act as a champion for personalised care and shared decision making within the PCN.
Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning.
Contribute to the development of policies and plans relating to equality, diversity, and reduction of health inequalities.
Work in accordance with the practices and PCNs policies and procedures.
Contribute to the wider aims and objectives of the PCN to improve and support primary care.
About us
We are a 6 practice PCN with approximately 65,000 patients. We are rapidly developing our multi-disciplinary workforce, embedding our roles, developing our team that makes a real difference to our patients and our practices. we pride ourselves on tackling the needs of our patients by working together to provide personalised health support for our population health needs.
Morley is a thriving area of South Leeds with a strong community. The area is a highly sought after place to live due to its excellent links to the city and busy town centre.
We would Welcome applicants who have a strong admin and people background.
Job description Job responsibilities
Enable access to personalised care and support
Take referrals or proactively identify people who could benefit from support through care co-ordination.
Have a positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance.
Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them.
Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.
Support people to develop and implement personalised care and support plans.
Review and update personalised care and support plans at regular intervals.
Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
Co-ordinate and integrate careMake and manage appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system.
Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.
Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a co-ordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
Actively participate in multidisciplinary team meetings in the PCN.
fIdentify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
Record what interventions are used to support people, and how people are developing on their health and care journey.
Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care co-ordination on their health and wellbeing.
Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
3. Supervision/professional development
Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required.
Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Access relevant GPs to discuss patient related concerns, and be supported to follow appropriate safeguarding procedures
Miscellaneous
Establish strong working relationships with GPs and practice teams and work collaboratively with other care co-ordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team.
Act as a champion for personalised care and shared decision making within the PCN.
cDemonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning.
Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities.
Work in accordance with the practices and PCNs policies and procedures.
Contribute to the wider aims and objectives of the PCN to improve and support primary care.
Person Specification
Experience Essential
Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement Experience of data collection and using tools to measure the impact of services understanding of how to use System 1 experience of working in primary care
Desirable
Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Experience of 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 working within multi - professional team environments Experience of supporting people, their families and carers in a related role Experience or training in personalised care and support planning
Other Essential
Access to own transport Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social
Qualifications Essential
GCSE A-C IN English and Maths Meets a Disclosure and Barring Service (DBS) reference standards and criminal record checks
Desirable
Administration qualifications
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 Morley and District PCN
Address Shenstone House Surgery
Elland Road
Morley
Leeds
LS27 7PX
United Kingdom
Employer's website https://www.leighviewmedical.co.uk/ (Opens in a new tab)