Vulnerable Patients Care Co-ordinator

Integrated Care System; Stockport; Hybrid; GBP 27,000 - 31,000; Full time

Job summary

An innovative system in Stockport is seeking a Vulnerable Patients Care Co-ordinator to enhance health outcomes for vulnerable patient groups. This role involves working closely with healthcare professionals to provide comprehensive care coordination and support for patients with learning disabilities and cancer. The position requires good communication skills and prior experience in a healthcare setting, ensuring effective service delivery and promoting health equity.

Benefits

Opportunities for training and development

Employee assistance program

Qualifications

• Experience working in healthcare, particularly with vulnerable patients.
• Ability to recognize and respond to safeguarding concerns.
• Proficient in using various IT systems for documentation.

Responsibilities

• Coordinate care for vulnerable patients within the PCN.
• Support patients with learning disabilities and cancer care.
• Engage in data collection and administrative duties.

Skills

Good communication

Interpersonal skills

Ability to manage workload

Education

NVQ Level III in Health and Social Care

Grade C or above in English and Maths GCSE

Tools

Clinical systems

Microsoft Office

Job description

We have a fantastic opportunity to join our innovative team of Care Co-ordinators working across the Stockport borough, specialising in care of vulnerable patient groups.

This role will involve working with individuals with learning disabilities, those requiring safeguarding oversight, and patients living with cancer.The Care Co-ordinator will be integral in overseeing the interdisciplinary care and will be responsible for co-ordinating a package of care and support from a variety of specialists who may be working with the patient.

You will support all key activity across the PCN; supporting the PCN Manager and associated practices by co-ordinating activity and providing an efficient, well organised administrative and operational support to the clinicians and managers in the network to ensure effective timely delivery of the PCN objectives.

Main duties of the job

CareCo-ordinator roles are new to Primary Care and we are looking to recruit a Vulnerable Patients Care Co-ordinator to work across the Stockport borough. This role aims to improve health outcomes, promote timely care, and reduce health inequalities through effective care planning, system navigation, and communication between patients, carers, and the healthcare team.The care co-ordinatorwill be integral in overseeing the interdisciplinary care and will beresponsible for co-ordinating a package of care and support from a variety ofspecialists who may be working with the patient.

About us

Viaduct Care CIC is the company structure for Stockport's GP Federation and represents all of its local GP Practices. Covering a patient population of circa 300,000 practices are split into 6 PCNs with each serving a population of around 30,000-50,000 patients.

Viaduct Care represents the collective voice and interests of its member practices and as a key stakeholder in Stockport Together aims to influence and support the design and delivery of major service and system changes by being a strong and effective partner with other major service providers.

One of our priorities at Viaduct Care is to ensure that wellbeing and development of our team is at the forefront of everything we do. We have recently launched our new employee assistance programme, assisting our team to get access to a range of advice 24 hours a day. Additionally, we are keen to provide opportunities for team members to develop and grow including access to an extensive range of training and up to five paid study days per year.

Click on the Why Join Viaduct Care link to the right to find out about all of our staff support and benefits.

Job responsibilities

Main Role and Responsibilities

To work as a team of Vulnerable Patient Care Coordinators, with the GPsand other primary care professionals within the PCN to proactively identify andsupport some of our most vulnerable patients who require additional input dueto their presentation. The focus being those patients with learningdisabilities, those on the safeguarding register, those with diagnosis ofcancer and to support with cancer screening uptake as well.

• Be flexible to work collaboratively and support the other carecoordinator teams across the PCN with work that is required as directed by thePCN management team.
• In some cases, especially when working with patients with learningdisabilities, to visit these patients in their own homes or see them within thepractice where appropriate to complete a holistic review of the patientshealth and social needs following an agreed assessment pathway.
• Data collection and submission, filing, general admin etc.
• Bring together all a persons identified care and support needs andwhat matters to them; explore the options to address these in a singlepersonalised care and support plan created in collaboration with the patientand their family as appropriate.
• Communicating at least monthly with the PCN management team aboutongoing workstreams and work completed.
• Raise awareness of shared decision-making and decision support toolsand assist people to be more prepared to have a shared decision-makingconversation.
• Assist people to access self-management education courses, peer supportor interventions that support them in their health and wellbeing; explore andassist people to access personal health budgets where appropriate.
• Support the coordination and delivery of multidisciplinary teams withinPCN, in particular working with the PCN Pharmacy team.
• Provide coordination and navigation for individuals and their carersacross health and care services, working closely with social prescribing linkworkers and other roles such as social services, school nurses, health visitorsand midwives.
• To help patients to manage their needs through answering queries,making, and managing appointments
• Assist and coordinate practices in meeting PCN DES, LocallyCommissioned Service Targets and Impact and Investment Fund (IIF) targets, andpractice Quality Outcomes Framework (QoF) targets.
• Promote vaccination, screening and health improvement across patientgroups
• Work closely with GPs, nurses, social prescribers and external agenciesto ensure coordinated care.

The role includes working together as ateam of care coordinators to support the below groups of patients. Some aspectsof the role are indicated under each heading.

• Maintainand update LD registers, ensuring accurate coding and data.
• Coordinateand promote annual LD health checks.
• Liaisewith GPs and nurses to allocate patients and schedule appointments in thecorrect order (care coordinator nurse GP).
• Completepre-health check reviews using the Ardens LD template
• Promotevaccinations (MMR, flu, COVID) and cancer screening.
• Liaisewith community and childrens LD teams when appropriate.
• Actas a point of contact for LD patients and carers for navigation and support.

2.Safeguarding

• Maintain andupdate adult and child safeguarding lists for aligned practices.
• Organise andminute bi-monthly safeguarding meetings, documenting outcomes in EMIS.
• Complete Child ProtectionCase Conference reports using EMIS templates and submit via the agreed process.
• Contact andsupport families of children awaiting CAMHS, offering signposting and welfarechecks.
• Monitor andrespond to DNAs for vulnerable children and adults, using appropriate templatesand flagging concerns.
• Liaise withsafeguarding leads and attend multi-agency meetings as appropriate.
• Support thewelfare of parents' mental health when capacity allows, using structuredcheck-ins and signposting.

3. CancerCare Coordination

• Conduct anddocument 3-month and 12-month cancer care reviews.
• Maintain theGold Standards Framework (GSF) register and ensure care plans/DNACPR status aredocumented and uploaded to EPAACs.
• Organise andminute monthly GSF meetings with practices, involving DNs/Macmillan asrequired.
• Promote cancerawareness campaigns and screening programmes (smear, bowel, breast) acrosspractices and actively follow up patients who have refused or not responded toscreening invitations.
• Support PCNaudit work on cancer diagnoses to identify improvement opportunities for earlydiagnosis.
• Monitor DNAsfor cancer and frail patients, identifying barriers and supportingre-engagement.

4. EDattendances and DNAs

• Monitor DNAsfor vulnerable patients, contacting patients/carers, identifying barriers, andsupporting re-engagement.
• Monitor A and Eattendances in under 18s, contacting families when appropriate to discussalternatives to ED, health needs, and safeguarding concerns.
• Use Ardenstemplates consistently to document contacts and interventions.

It should benoted that whilst this job description lists the main areas of responsibility,there may be additional tasks appropriately assigned by either the ClinicalDirector or PCN Lead Manager to this role to meet the needs of our patients inan ever changing healthcare environment.

Person Specification

Experience

• Previous experience working in healthcare, care or community setting
• Experience of working autonomously and part of a team
• Ability to recognise and respond appropriately to risk and safeguarding concerns
• Knowledge around importance of confidentiality and data protection
• Experience of working in Primary Care
• Experience of working with Cancer/Learning Disabilities/Safeguarding
• Experience using clinical systems and MS office for record driving
• Evidence of working within a multidisciplinary team
• Previous experience of care coordination, learning disabilities, safeguarding or cancer care

Skills and Other

• Good communication and interpersonal skills, including an ability to build rapport and establish good one to one relationships
• Ability to deal with challenging behaviour and difficult conversations
• Be able to offer support in a person centred and non-judgmental way
• Ability to effectively manage a variable workload
• Ability to maintain accurate and concise records
• Ability to provide information effectively
• Good IT skills and proficient in the use of various Microsoft packages
• Willingness to work in settings across Stockport
• Commitment to working towards Viaduct Care CICs values and ethos as an organisation
• Commitment to reducing health inequalities and improving outcomes for vulnerable groups
• Must drive and have access to a vehicle for work-related travel across sites and for potential home visits
• Experience of working without direct supervision

Additional Attributes

• Willingness to work and travel in settings across Stockport and ability to work from home if required.
• Commitment to working towards Viaduct Care CIC's values and ethos as an organisation.
• Have a full, clean driving license and have access to a car during all contractual hours.
• Ability to work flexibly in an innovative and developing role.

Qualifications

• Achieved grade C or above, in English and Maths GCSE or equivalent
• NVQ Level III (Health and Social Care) or equivalent or equivalent experience
• Formal training in working with long term conditions.

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.

£27,485 to £30,162 a yearPro rata based on 37.5 hours per week