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Job description

Job summary

ABC provide employment and management support to the Healthy Horley Primary Care Network comprising the following practices:

• Birchwood Medical Practice
• Smallfield Surgery
• Wayside Surgery

This role is to support the smooth coordination of care across the Horley Primary Care Network.

The coordinator will support the PCN Anticipatory Care Hub in identifying and managing a caseload of patients, referring patients to health and social professionals as needed and providing and organising PCN Multi-Disciplinary Team Meeting on a regular basis.

The salary is £22,607.47 to £25,459.68 a year, depending on experience.

About us

Alliance for Better Care CIC is a GP Federation that unites 47 NHS GP practices across 12 Primary Care Networks in Sussex and Surrey. We support our Primary Care colleagues as well as their patients, to transform how healthcare is managed within the community.

As a membership organisation, our focus is to work in partnership with our members and help them to improve the provision of General Practices in the local area.

We work with and listen to our GP Practices, PCNs, Hospitals, Community Organisations and the Third Sector. These vital partnerships ensure that, together, we deliver a truly integrated approach that offers the support and expertise needed to effectively serve our communities.

Job description

Key Responsibilities and Duties

• To work across a Primary Care Network supporting a wide range of patients of all ages living within Care Homes and living independently (Residential, Nursing, Learning Disability)
• Utilising soft and hard intelligence within the PCN to identify patients who will benefit from a proactive approach by the PCN, the wider community and multidisciplinary teams
• Identifying patients to discuss at PCN level MDTs where a multiple professional group attend to discuss the most complex patients, in a view to reducing unplanned admissions and exacerbation of conditions
• Coordinating and supporting the running of the weekly MDT meetings ensuring that relevant professionals are in attendance
• Uploading and maintaining patient care plans to EMIS and other relevant systems as necessary
• Maintaining action logs to audit outcomes and being able to give updates to professionals from multiple providers across the PCN, including the patients, carers and next of kin
• Ensuring all Care Homes within the PCN have a weekly check in. Phoning patients in their own homes regularly who have been identified as needing clinical and social support
• Identifying patients with and without care plans, to ensure they are up to date and shared with other agencies including the ambulance service
• Keeping up to date records in all GP clinical systems across the PCN, including data that can be reported on and shared with the PCN for outcomes, on a monthly basis
• Maintaining action logs to audit outcomes and being able to give updates to professionals from multiple providers across the PCN, including the patients, carers and next of kin
• Arranging GP ward rounds to Care Homes
• Liaising with Acute Trusts, Hospices, Community and Social Care providers as required
• Ensuring Templates are completed by professionals in order to provide accurate data, by encouraging there use and auditing regularly to ensure adherence
• Collate monthly data from each Practice within each PCN. To work with the ABC Data Analyst to compile monthly data that can be shared with the PCNs and the CCG.

Record Keeping and General Responsibilities

• To keep accurate and up-to-date records of their contact with patients, carers and professionals, including the use of GP databases such as EMIS/SystmOne
• To use read codes to tag those patients identified for interventions and must be placed on the patients record, so that activity and metrics associated with these patients can be tracked over time by the PCN to monitor outcomes and provide data for proof of concept
• To collect data in a prescribed format as required, in order to demonstrate the impact of the service
• To actively engage with the practice teams within the PCN, ensure effective liaison with all PCN staff and contribute to the overall aims of the PCN
• To attend and contribute to relevant meetings.

Miscellaneous

• Work as part of the team to seek feedback, continually improve the service and contribute to business planning
• 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.

Person Specification

Qualifications

Essential

• Demonstrable commitment to professional and personal development

Desirable

• NVQ Level 3, Advanced level or equivalent qualifications or working towards
• Training in motivational coaching and interviewing or equivalent experience

Experience

Desirable

• Experience of working directly in either the NHS or Adult Social Care

Personal Qualities & Attributes

Essential

• Ability to listen, empathise with people and provide person- centred support in a non-judgemental way
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from all communities
• Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
• Ability to identify risk and assess/manage risk when working with individuals
• Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
• Excellent IT skills including Excel, knowledge of GP systems
• Able to provide leadership and to finish work tasks
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• Commitment to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues
• Demonstrates personal accountability, emotional resilience and works well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• High level of written and oral communication skills
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Understanding of the needs of small volunteer-led community groups and ability to support their development
• Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety

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.

Job Types: Full-time, Permanent

Salary: £22,607.47-£25,459.68 per year

Benefits:

• Company pension
• Cycle to work scheme
• Sick pay

Schedule:

• Day shift
• Monday to Friday

Ability to commute/relocate:

• Horley, Surrey: reliably commute or plan to relocate before starting work (required)

Work authorisation:

• United Kingdom (required)

Work Location: One location