Job Description

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Job Purpose

Care Co-ordinator roles are new to Primary Care and we are looking to recruit two Vulnerable Patient Care Co-ordinators within the SES Primary Care Network (PCN) across the borough. This role will involve working with patients with a range of presentations including Frailty and Dementia, falls, to individuals with learning disabilities and those requiring safeguarding oversight. 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. The 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-ordinator 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 Roles & Responsibilities:

To work as a team of Care Coordinators, with the GPs and other primary care professionals within the PCN to proactively identify and support some of our most vulnerable patients who require additional input due to their presentation. The focus being those patients with moderate to severe frailty, those with a diagnosis of dementia or cognitive impairment, and those returning home after a recent admission to hospital, with the aim of delivering proactive and reactive care to this group of patients. In addition to this, the role may include patients with learning disabilities, those on the safeguarding register, those with diagnosis of cancer and to support with cancer screening uptake as well. Be flexible to work collaboratively and support the other care coordinator teams across the PCN with work that is required as directed by the PCN management team. Be responsible for running weekly EMIS searches to identify those moderately and severely frail patients, those with recent admissions to hospital or ED attendances, particularly those attending with falls and those with known dementia, contacting patients to arrange appointments, whether in their own homes or bringing them into clinic. To visit these patients in their own homes or see them within the practice where appropriate to complete a holistic review of the patients health and social needs following an agreed assessment pathway. Data collection and submission, filing, general admin etc. Bring together all a person's identified care and support needs and what matters to them; explore the options to address these in a single personalised care and support plan created in collaboration with the patient and their family as appropriate. To support with venepuncture and NHS Health Checks (pulse measurement, blood pressure monitoring, height and weight measurement and waist measurement) where required. Communicating at least monthly with the PCN management team about ongoing workstreams and work completed. Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing; explore and assist people to access personal health budgets where appropriate. Support the coordination and delivery of multidisciplinary teams within PCN, in particular working with the PCN Pharmacy team. Provide coordination and navigation for individuals and their carers across health and care services, working closely with social prescribing link workers and other primary care roles such as the Advanced Community Practitioners/District nurses. To help patients to manage their needs through answering queries, making, and managing appointments. Assist and coordinate practices in meeting PCN DES, Locally Commissioned Service Targets and Impact and Investment Fund (IIF) targets, and practice Quality Outcomes Framework (QoF) targets. Responsible for coordinating any joint projects, e.g. vaccination and any associated administration.
It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role.

This list of duties is not intended to be exhaustive, but indicates the main areas of work and may be subject to change after consultation with the post-holder and the wider team to meet the changing needs of the service

Standard Clauses

Performance Management

Objectives for the post will be the subject of overall agreement and regular review between the post-holder and their line manager. This will via regular supervision and the organisations Performance Development Review (PDR) 'Aspire and Perform' process.

Confidentiality and Compliance with the Data Protection Act 2018

The post holder must maintain confidentiality regarding information about patients, staff and other Viaduct Care business in accordance with the Data Protection Act 2018. All employees of Viaduct Care must not, without prior permission, disclose any information regarding patients or staff. In circumstances where it is known that a member of staff has communicated information to an unauthorised person, those staff will be liable to dismissal. Moreover, the Data Protection Act 2018 also renders an individual liable to prosecution in the event of unauthorised disclosure of information.

Health and Safety

All employees must be aware of the responsibilities placed on them under the Health and Safety at Work Act 1974 to ensure that the agreed safety procedures are carried out to maintain a safe working environment for patients, visitors and employees. Review and ensure systems are in place for the proactive management of risk registers.

Infection Control

All employees of Viaduct Care are required to contribute to the management of infection control and be proactive in awareness raising and prevention. Ensure that all guidelines, protocols and procedures undertaken within the service are in line with evidence based practice for infection control.

Safeguarding Children and Adults

All staff are required to act in such a way that at all times safeguards and promotes the health and well-being of children and vulnerable adults. Familiarisation with and adherence to the policies and procedures of the Local Safeguarding Boards (Children and Adults) and those of Viaduct Care is an essential requirement of all staff as is participation in mandatory safeguarding training in accordance with individual roles and responsibilities.

Equality and Diversity

Employees should promote diversity and equality of opportunity within Viaduct Care. Build a culture where everyone is valued and equipped to do their job. All employees must carry out all duties and responsibilities of the post in accordance with Viaduct Care's Equality, Diversity and Human Rights policies, avoiding unlawful discriminatory behaviour and actions when dealing with colleagues, service users, members of the public and other stakeholders.

Sustainability

All employees of Viaduct Care have a responsibility for working in a low carbon environment, where energy is used wisely and not wasted. Environmental impact should be reduced by recycling where possible, switching off lights, computers, monitors and equipment when not in use, minimising water usage and reporting faults promptly.

Person Specification (E=Essential; D=Desirable)

Qualifications

Achieved grade C or above, in English and Maths GCSE or equivalent - E Formal training in venepuncture (or be willing to work towards this) - E NVQ Level III (Health and Social Care) or equivalent experience. - D Formal training in working with long term conditions - D PCI Accredited Care Coordinator training (or be willing to work towards this) - D

Knowledge and Experience

Committed to improving outcomes for older adults - E Experience of working autonomously and part of a team - E Ability to recognise and respond appropriately to risk and safeguarding concerns - E Knowledge around importance of confidentiality and data protection - E Experience of working with older adults, including those with dementia, frailty or at risk of falls - E Understanding of dementia, frailty syndromes and falls risk in older adults - E Knowledge and understanding of Adult Social Care frameworks, policies, and local service provision - D Ability to undertake and interpret relevant clinical observations and tests (e.g., BP, MUST score, bloods) or willing to learn - D Experience in using care planning templates (e.g. Ardens) and digital systems - D Understanding of polypharmacy and medication reviews (liaising with SIPS/clinical pharmacist team) - D Evidence of working within a multidisciplinary team. - D

Skills

Good communication and interpersonal skills, including an ability to carry out DNAR and future planning discussions sensitively and appropriately - E Ability to carry out comprehensive assessments including: dementia reviews, frailty assessments and falls risk assessments - E Be able to offer support in a person centred and non-judgmental way - E Ability to plan and prioritise workload independently - E Ability to maintain accurate and concise records - E Ability to provide information effectively - E Experience of working without direct supervision - D

Other

Good IT skills and proficient in the use of various Microsoft packages. - E Willingness to work and travel in settings across Stockport and ability to work from home if required. - E Have a full, clean driving license and have access to a car during all contractual hours. - E Commitment to working towards Viaduct Care CIC's values and ethos as an organisation - E Ability to work flexibly in an innovative and developing role - E
Job Type: Full-time

Pay: 27,485.00-30,162.00 per year

Benefits:

Additional leave Bereavement leave Company pension Cycle to work scheme Enhanced maternity leave Free flu jabs Health & wellbeing programme Sick pay
Application question(s):

Do you have a full driving licence and use of a car?
Work authorisation:

United Kingdom (required)
Work Location: In person