Patient Care Coordinator

Job Description

A patient care co-ordinator (PCC) may be required to deal with patients and, if appropriate, their carer, before or after the patient’s consultation with a clinician or other healthcare professional.

Working closely with the patient and their clinician or other healthcare professional, the PCC co-ordinates patients’ healthcare and directs them to the appropriate service to ensure that they get the most suitable care from whatever health or social care provider is appropriate.

The PCC’s role requires them to be able to work with, and understand the roles of, a variety of different people working in the practice and across the PCN including doctors, nurses, healthcare assistants, social prescribing link workers, physiotherapists, physician associates, paramedics, health and wellbeing coaches, podiatrists, occupational therapists and pharmacy technicians.

They may be given a caseload of identified patients and be required to ensure that their changing needs are addressed by taking into account local priorities, health inequalities and/or population health management risk stratification.

All staff at The Royal Parks have a duty to conform to the following:

Equality, Diversity and Inclusion

A good attitude and positive action towards ED&I creates an environment where all individuals are able to achieve their full potential. Creating such an environment is important for three reasons – it improves operational effectiveness, it is morally the right thing to do and it is required by law.

Patients and their families have the right to be treated fairly and be routinely involved in decisions about their treatment and care. They can expect to be treated with dignity and respect and will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Patients have a responsibility to treat other patients and our staff with dignity and respect.

Staff have the right to be treated fairly in recruitment and career progression. Staff can expect to work in an environment where diversity is valued and equality of opportunity is promoted. Staff will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Staff have a responsibility to ensure that they treat our patients and their colleagues with dignity and respect.

Safety, Health, Environment and Fire (SHEF)

This PCN is committed to supporting and promoting opportunities for staff to maintain their health, well-being and safety.

The post holder is to manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients and monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines.

All personnel have a duty to take reasonable care of health and safety at work for themselves, their team and others and to cooperate with employers to ensure compliance with health and safety requirements. All personnel are to comply with the Health and Safety at Work Act 1974, Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.

Confidentiality

The PCN and associated practices are committed to maintaining an outstanding confidential service. Patients entrust and permit us to collect and retain sensitive information relating to their health and other matters pertaining to their care. They do so in confidence and have a right to expect all staff will respect their privacy and maintain confidentiality at all times.

It is essential that, if the legal requirements are to be met and the trust of our patients is to be retained, all staff protect patient information and provide a confidential service.

Quality and Continuous Improvement (CI)

To preserve and improve the quality of PCN outputs, all personnel are required to think not only of what they do but how they achieve it. By continually re-examining our processes, we will be able to develop and improve the overall effectiveness of the way we work.

The responsibility for this rests with everyone working within the PCN and practices to look for opportunities to improve quality and share good practice and to discuss, highlight and work with the team to create opportunities to improve patient care.

The Royal Parks continually strives to improve work processes which deliver healthcare with improved results across all areas of our service provision. We promote a culture of continuous improvement where everyone counts and staff are permitted to make suggestions and contributions to improve our service delivery and enhance patient care.

Staff should interpret national strategies and policies into local implementation strategies that are aligned to the values and culture of general practice.

All staff are to contribute to investigations and root cause analyses whilst participating in serious incident investigations and multidisciplinary case reviews.

Induction

In addition to the induction process at The Royal Parks, where you will be provided with a full induction programme, when attending any practice within the network you will also be required to complete their practice induction programme.

Whilst across the PCN we aim to standardise this process, inevitably there will be nuances particular to each practice. In any such instance, the practice management team will support you with this.

Learning and development

The effective use of training and development is fundamental in ensuring that all staff are equipped with the appropriate skills, knowledge, attitude and competences to perform their role. All staff will be required to partake and complete mandatory training as directed by the Lead Practice Manager. It is an expectation for this post holder to assess their own learning needs and undertake learning as appropriate

The post holder will undertake mentorship for team members and disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments (e.g. courses and conferences).

The post holder will provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning.

Collaborative working

All staff are to recognise the significance of collaborative working and understand their own role and scope and identify how this may develop over time. Staff are to prioritise their own workload and ensure effective time-management strategies are embedded within the culture of the team.

Teamwork is essential in multidisciplinary environments and the post holder is to work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working. To work effectively with others to clearly define values, direction and policies impacting upon care delivery

Effective communication is essential and all staff must ensure they communicate in a manner which enables the sharing of information in an appropriate manner.

All staff should delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence.

Plans and outcomes by which to measure success should be agreed.

Managing information

All staff should use technology and appropriate software as an aid to management in the planning, implementation and monitoring of care and presenting and communicating information.

Data should be reviewed and processed using accurate SNOMED/read codes in order to ensure easy and accurate information retrieval for monitoring and audit processes.

Service delivery

Staff will be given detailed information during the induction process regarding policy and procedure.

The post holder must adhere to the information contained within PCN and local practice policies and regional directives, ensuring protocols are adhered to at all times.

Primary responsibilities

The following are the core responsibilities of the PCC.

There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels and the availability of a social prescribing link worker within the PCN:

Patient Identification

• Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.
• Liaise with service providers and clinicians to identify ‘frequent flyers’, and new service users utilising risk stratification tools provided and present this information to the bi-weekly MDT meetings.
• Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT.
• Signpost team members, service users and carers to relevant services

Multi-Disciplinary Teams

• Overall responsibility for arranging the bi-weekly PCN led MDT meetings (including the weekly virtual Care Home(s) MDT) and the smooth running of integrated care within the team setting. The key role of the Care Coordinator will be to schedule the bi-weekly MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
• Coordinate and manage the administrative functions of MDT meetings.
• Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
• Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
• Manage reporting required and associated within the DES specifications for required services.

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.
• 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 service users, PCN practices and partners e.g. Care Homes to ensure new referrals are logged and allocated
• 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
• Acting as a point of contact for residents, families and professionals who visit the care home, such as MDT members and in-reach specialists.
• Meet regularly with the clinical lead and review case load and MDT function.
• Keep the MDT and Royal Parks organisation abreast of ‘good news’ stories.
• Provide background information about individuals for the bi-weekly MDT meetings
• Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public
• Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT

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 Practice’s 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.

Patient Care

• Communicate effectively and sensitively and use language appropriate to a patient and carer/relative’s 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 service users 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 service users 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

Secondary responsibilities

In addition to the primary responsibilities, the PCC may be requested to:

• Support delivery of QOF, incentive schemes, QIPP and other quality or cost effectiveness initiatives
• To co-ordinate our Mental Health checks.
• To maintain our Carers award and work towards Gold
• To maintain our veterans list
• To liaise with our Safeguarding lead and follow up on any discharges from hospitals
• To work with the GP’s and build a relationship with the care homes to ensure patient care.
• Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner
• Duties may vary from time to time without changing the general character of the post or the level of responsibility

The Successful candidate will be based at Langham Place Surgery.

Closing Date - 6th June

Job Type: Full-time

Pay: £24,851.23-£28,351.13 per year

Benefits:

• Company pension
• Free flu jabs
• Free parking
• On-site parking

Experience:

• system one: 1 year (required)
• GP surgery: 1 year (required)

Licence/Certification:

• Driving Licence (preferred)

Work Location: In person