Job Description

Duties may be varied from time to time under the direction of the QOF Lead dependent on current and evolving Practice workload and staffing levels: Working with the primary care team, identify cohorts of patients who require annual reviews. Contact and work with these patients to organise review appointments. Check and ensure each patient understand and considers the options and choices available to them. Source and provide patients with relevant and appropriate information to support shared decision making.



Collate patient data with best practice and upload and regularly update the patient record. Be responsible for improving healthcare outcomes by leading Quality and Outcomes Framework (QOF) work in the practices. Create, amend and use searches within the clinical system to identify cohorts of patients. Create, amend and produce letter/text templates for the individual practices.



Produce protocols and spreadsheets to provide audit. Assist the patient to navigate and progress through the relevant pathways, processes and systems, answering patient questions, making phone-calls, appointments, arrangements for care, liaising with professionals, service personnel and wider stakeholders. Implement new pathways for effective follow-up of patients with Long Term Conditions. Implement a process for safety-netting at the practice, so patients are followed up effectively.



Ensure that knowledge of clinical IT systems is up to date and ensure the effective utilisation of these systems. Be familiar with, and maintain up to date knowledge of the GP and PCN Enhanced Service requirements, regarding QOF. Attend regular training and webinars to keep up to date with the contract changes. Work in a safe and organised manner.



Work with the other PCN Care Coordinators to share learning and best practice. Build and maintain effective relationships with the practice teams and PCN staff. Organise and participate in Practice management, reception and PCN Meetings. Observe and comply with appropriate statutory requirements in relation to Child and Adult Safeguarding and to be familiar with the reporting process could this be required.



Undertake mandatory training. Comply with Data Protection and Information Governance regulations and policies. Confidentiality: While seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.



In the performance of the duties outlined in this , the post-holder will have access to confidential information relating to patients and their carers, PCN and practice staff and other healthcare workers. They may also have access to information relating to the PCN or practices as business organisations. All such information from any source is to be regarded as strictly confidential. Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice and PCN may only be divulged to authorised persons in accordance with the Practice and PCN policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health & Safety:

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in practice Health & Safety Policies, practice Health & Safety Manuals, and practice Infection Control Policies and published procedures. This will include: Using personal security systems within the workplace according to Practice and PCN guidelines. Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks. Making effective use of training to update knowledge and skills.



Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards. Actively reporting of health and safety hazards and infection hazards immediately when recognised. Keeping own work areas and general / patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holders role. Undertaking periodic infection control training via e-learning modules.



Reporting potential risks identified to key personnel. Equality & Diversity: The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include: Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with Practice and PCN procedures and policies, and current legislation; Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues; and Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights. Personal/Professional Development: The post-holder will participate in any training programme implemented by the Practice and/or PCN as part of this employment, such training to include: Participation in an individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development. Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.



Working with clinicians in stages when working out templates for the Quick Message system and or training. Quality: The post-holder will strive to maintain quality within the Practice and PCN, and will: Alert other team members to issues of quality and risk. Assess own performance and take accountability for own actions, either directly or under supervision. Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.



Work effectively with individuals in other agencies to meet patients needs. Effectively manage own time, workload and resources. Communication: The post-holder should recognise the importance of effective communication within the team and will strive to: Communicate effectively with other team members; Communicate effectively with patients and carers; Recognise peoples needs for alternative methods of communication and respond accordingly; and Contribute to the Implementation of Services. The post-holder will: Apply practice and PCN policies, standards and guidance.



Discuss with other members of the team how the policies, standards and guidelines will affect own work. Participate in audit where appropriate. Assist the PCN to deliver on the requirements of the PCN DES Contract, quality initiatives, public health initiatives.