Burmantofts, Harehills and Richmond hill PCN Care Coordinator

NHS; Leeds; On-site; GBP 24,000 - 30,000; Full time

Job summary

A leading healthcare organization in Leeds is seeking a motivated Care Coordinator to support patient care and address health inequalities. The ideal candidate will work within a multidisciplinary team to manage and coordinate care for individuals with long-term health conditions. This role requires excellent communication skills, teamwork capability, and experience in healthcare settings. The position offers a rewarding opportunity to improve community health outcomes.

Qualifications

• Excellent knowledge of Microsoft Office and Excel.
• Able to deal with service users sensitively.
• Demonstrate the importance of cultural factors in communicating with people.

Responsibilities

• Support patients and practices in appointment bookings for target groups.
• Liaise with all clinical and non-clinical members in the multi-disciplinary team.
• Manage and support PCN clinical system hub unit, rotas and smart card access.

Skills

Excellent written and verbal communication skills

Ability to work as part of a team

Strong analytical and judgement skills

Ability to manage own workload

Experience providing advice/signposting

Education

ECDL or equivalent

Long term conditions training

Tools

Microsoft Office

Clinical System experience

Job description

Burmantofts, Harehills and Richmond hill PCN Care Coordinator

We are looking for a highly motivated team player to work alongside others in BHRPrimary Care Network. This role will provide support to practices within the PCN to manage, identify and provide coordination of care for a range of people, particularly those with long-term conditions and multiple long-term conditions. The BHR PCN approach is to provide a health population to support and influence the health of a community and its patients to tackle health inequalities.

The successful candidate will work alongside a multi skilled and proactive Population Health Management Hub team to deliver a safe and effective service, developing new ways of working and pathways in accordance with key local and national clinical standards. The role will help people co-ordinate and navigate their care across the health and care system.

Main duties of the job

Care Coordinator Job Description

Responsible to: Burmantofts, Harehills and Richmond Hill Primary Care Network (BHR PCN)Accountable to: Service Lead for the PopulationHealth Management Hub

The CareCoordinator will be part of the Primary Care Network (PCN) Multi-Disciplinary Team (MDT) who are responsible for managing the care of people registered with practices within BHR PCN.

A key part of the role of a care coordinator role is working in the Population Health Management Hub and working with the service lead.

The Population Health Management Hub is a team of the PCN staff that provide support to practices within the PCN to manage , identify and provide coordination of care for the PCN population. The hub approach ensures that a central team are focused on proactively seeking frameworks and models of care for priority patients within the PCN and its local context.

The Population Health Management Hub will support the PCN approach to health population management by coordinating personalised care by prioritising patients in highest risk group, delivering strategies that engage wider workforce and digital/tech to optimise self-care and remote care.

About us

How you will tackle health inequalities in BHR PCN, caring for patients with long-term conditions and mental health (multimorbidity) is sadly very common and is a known priority for BHR PCN. We think this is a challenging but very rewarding opportunity for a care coordinator to join our committed and dedicated team that tackle these health inequalities daily. Our population have a higher prevalence of mixed mental and long-term conditions because of the nature of our more deprived communities, particularly at an earlier age. Along with our culturally diverse population, these multimorbidity patients are service priority.

Job responsibilities

The Population Health Management Hub will also be central to developing solutions to unplanned care by understanding what factors are driving poor outcomes in different population groups. Ensuring the PCN are designing and planning models of care which will improve health and wellbeing today and also in the future.

This will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population.

The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions, SMI and Obesity . An ethos of promotion of independence and partnership-working is integral to this post.

Primary Duties and Areas of Responsibility

• Support patients and practices in appointment bookings for target groups of patients.
• Supporting patients to complete questionnaires to identify and assess their levels of wellbeing and skills, knowledge to manage their own health.
• Liaise with all clinical and non-clinical members in the multi-disciplinary team (MDT).
• Support management and allocation of referrals into the personalised care team.
• Support reporting requirements associated within the DES specifications for required services.
• Support reporting to strategic team any systematic trends of potential threats and their implications or opportunities and likely future developments.
• Manage and support PCN clinical system hub unit, rotas and smart card access.
• Answer and take calls from internal PCN staff and external MDT members about patients receiving care from the personalised care team and other PCN MDT staff as appropriate.
• Performing administrative tasks (including appointments, diaries, patient searches).

Patient Identification

Receive and collate information from clinical systems to understand what factors are driving poor outcomes in different population groups.

• Use search tools for risk stratification of patients.
• Review end of year QoF data for the PCN.

Maintenance of IT based information systems and responsibility for key performance data:

• To ensure the IT requirements for recording activity are adhered to in collaboration with other team members
• Accurate update and maintenance of GP systems within the MDT.
• To provide agreed performance/activity data within the MDT and PCN and wider BHR PCN.

Communication and collaborative working relationships

• Demonstrates ability to work as a member of a team.
• Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary.
• Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.
• Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations.
• Work with patients, PCN practices and partners.
• Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT.
• Meet regularly with the service lead and review prioritisations.
• Keep the MDT and BHR PCN abreast of good news stories.
• Manage and prioritise workload on a daily basis and deal with the competing demands.

Other responsibilities

• To act at all times in an anti-discriminatory manner.
• To be able to plan and respond to workload according to operational priorities.
• To support the delivery of these functions across wider locality areas where necessary.
• To undertake any training required in order to maintain competency including mandatory training.
• To contribute to, and work within a safe working environment.
• The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures.
• The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.
• The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.
• Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding.
• Effectively use all methods of communication and be aware of and manage barriers to communication.
• Effectively recognise and manage challenging behaviours, carers and or relatives.
• Provide information to patients, their carers and/or relatives on behalf of the team.

Supporting Care Delivery

• Be the point of liaison for patients and interface with all health and social care professionals, including keeping everyone informed and updated.
• Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.
• Follow through with patients and others involved to ensure all services and care arrangements are in place.

Autonomy/Scope within Role

The post holder will be required to work within clearly defined organisational protocols, policies and procedures.

Key Relationships Key Working Relationships Internal:

• Service Lead for the PHMH.
• GPs and General practice teams within the PCN.
• PCN Clinical Director/s.
• MDT members including but not exhaustive: Clinical Pharmacists, technicians, Physician Associates, Physios, Paramedics, Social Prescribing Link Workers, Patient Ambassadors, health and wellbeing coach, practice managers.

Key Working Relationships External:

GPs from neighbouring PCNs

Service providers

Voluntary services

Carers/relatives

Health and Safety/Risk Management

• The post-holder must comply at all times with the organisation and Practices Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System.
• The post-holder will comply with the Data Protection Act (1984), The General Data Protection Regulations (2018) and the Access to Health Records Act (1990).
• The post-holder will comply with all necessary training requirements relevant to the role as identified by the organisation.

Equality and Diversity

The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc.

Respect for Patient Confidentiality

The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.

Special Working Conditions

The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies.

Job Description Agreement

This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.

Person Specification

Skills and Attributes

• Excellent written and verbal communication skills and interpersonal skills
• Evidence of excellent knowledge of Microsoft Office and Excel
• Able to deal with service users sensitively
• Able to work as part of a team
• Able to prioritise and manage own workload
• Excellent motivational and influencing skills
• Car user (to travel between more than one GP practice and events)
• Excellent interpersonal skills
• Strong analytical and judgement skills
• Ability to analyse and interpret information and present results in a clear and concise manner
• Excellent organisational and administration skills
• Uphold the principles of confidentiality. (Data protection and GDPR)
• Maintain a calm and sensitive approach when dealing with people in distress
• Demonstrate the importance of cultural factors in communicating with people
• Experience providing advice/signposting to users
• Clinical System experience

Values, Drivers and Motivators

• Willingness to undergo further training or development as the job develops
• Requires a flexible approach, and a highly motivated post holder. The role may need to be reviewed and developed in the future in line with changing priorities
• Access to and ability to use transport as travel between sites across Leeds may be required for meetings and training.

Aptitude and Personal Qualities

• Professional attitude and assertive approach
• Committed to development
• Conscientious, hardworking and self- motivated to work with minimal supervision
• Creative and tenacious in finding solutions to difficult problems
• Ability to work with information, clinicians, social workers and managers
• Ability to meet deadlines and work under pressure
• Ability to engage and sustain relationships with all professionals, other organisations and patients
• Approachable and flexible
• Honest and reliable
• Sensitive to patients needs
• Act in ways to promote values of equality and diversity

Experience

• Experience in use of databases
• Experience of administrative duties
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality
• Working in a multi-disciplinary setting where influence and negotiation is required
• Understand and use common social and health terminology.
• Working in a busy and demanding environment whilst delivering in a timely manner
• Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
• Understanding of current issues facing the NHS
• Understanding of health and social care processes

Qualifications

• ECDL or equivalent
• Ongoing internal and external training to keep up to date with changes/ developments
• Long term conditions training
• Welfare Rights basic training

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.