Senior Care Coordinator
Job Description
Job summary
Whitby Coast and Moors Primary Care Network are looking to recruit an enthusiastic and compassionate Senior Care Coordinator. Our PCN is setting up a new multidisciplinary holistic care team to provide dedicated support and care for patients with complex needs. The team will care primarily, but not exclusively, for older adults.
You will have the opportunity to share in the development of this new team which will focus on health, wellbeing and independence.
You will need to have clarity of professional identity and be comfortable working with a degree of uncertainty as new services are tested and developed.
In this new team there will be plenty of opportunity to use your service development, leadership and excellent clinical skills as you work with others to improve outcomes for patients.
If you are excited by the chance to work in a brand new team designed to make a real difference to patients' lives, and based in a beautiful area, please consider this role.
Main duties of the job
This key role will be embedded in the PCN Pilot and Transformation Team within Whitby Coast and Moors Primary Care Network, which supports system wide collaborative working to deliver multiple projects in work streams.
You will have continuing responsibility for identifying, proactive assessment, monitoring and management of patients and ensuring care is current, evidence based and in line with practice standards. You will provide leadership to the team in evaluation and monitoring of the service, provide specialist assessment as per the service users, and carers requirements.
You will lead with other senior colleagues the continuing development of a high-quality service that is underpinned by evidence-based practice and care pathways / packages and NICE guidance.
You will be required to engage a range of key partners and stakeholders, and lead on joint working across health and social care. They will need to work closely with colleagues within the PCN, Practices and ICB, councils, and the voluntary and community sector. You will also work alongside our primary care locality groups to support them in meeting their priorities around prevention and self-care.
About us
Whitby Coast and Moors PCN was founded in 2020 and consisted of 5 GP surgeries namely, Whitby Group Practice, Sleights and Sandsend Medical Practice, Danby Surgery, Egton Surgery and Staithes Surgery with a population in the region of 25,500 patients. Since inception the patient population has grown to approximately 27,010 and Danby and Egton surgeries merged to become Esk Valley Medical Practice.
Our teams consists of a highly skilled group of clinical, administrative and reception staff. We have a progressive attitude, are a very forward-thinking PCN with a passion for delivering excellent patient care and are always looking for new ways to work innovatively and efficiently.
We are situated within the beautiful area of Whitby and the surrounding Esk Valley.
Job responsibilities
Key Responsibilities:
Core Clinical Function
Provide a welcoming, compassionate, and professional service to all patients.
Offer guidance and reassurance during procedures or assessments.
Ensure patients dignity, privacy, and confidentiality are respected at all times
Aid in identifying patients with highly complex needs who would benefit from intervention
Manage and oversee management and care of service users with highly complex
needs
Produce accurate and timely documentation, conduct and manage the maintenance
of accurate and timely documentation / records on all service users in line with your
Professional Code of Conduct and PCN / Practice policy
Conduct and supervise assessment and observation to ensure appropriate and
timely feedback to the team
Conduct, supervise and oversee risk assessments of the individual highly complex
cases and the potential hazards in the service users environment
Provide professional clinical input at multi-disciplinary meetings i.e. referral /
review / business, professional or safeguarding meetings
Report and document incidents as required and act upon findings as appropriate
Act as a care coordinator in highly complex cases
Assess and review care and support and supervise lower banded staff in this
Process
Phlebotomy, Electrocardiographs (ECG's), Blood pressure monitoring, Carers reviews, NHS Health Checks, Urinalysis Health education including promoting the health benefits of a healthy diet, smoking cessation, weight management, health screening of patients with pre-Diabetes and diabetic foot checks, Ordering of clinical stock, home visits
Shared responsibility for teams' administration of medications, assessment of side effects,
review concordance and clinical effectiveness of medication regime in line with Practice / PCN
policy including
Accurately record patient information on EMIS clinical system
Safe transportation and storage of medicines, checking receipt, storage of
medicines in medicine cupboard
Providing education around the medication prescribed, side effects, actions
and aids to compliance
Provide practical support, guidance and education for services users, carers and
other professionals as required
Provide specialist assessment and intervention commensurate with skills and training
with colleagues where required
Be competent in use of relevant screening and assessment tools, supervise and train lower banded staff in their use
Actively take part in comprehensive assessment, care planning, treatment and review of care
Participate in formulation, delivery and review of individualised evidence-based care / care packages according to NICE guidance including non-medication strategies
Lead in the continuing development of a high-quality service and contribute to local emergency plan, team risk assessment etc. that is underpinned by evidence-based practice, care pathways / packages and NICE
Identify, assess and manage clinical and non-clinical risks / hazards in your area through the completion of the relevant risk assessments and the implementation of risk treatment plans for inclusion in the local and PCN's risk registers
Undertake physical health checks of service users and ensure team act on the findings appropriately
Understand the eligibility criteria and assessment process
Manage and coordinate multi-disciplinary meetings i.e. referral / review / business / handover in conjunction with the Clinical Lead, take a lead role in clinical service development and review
Identify aspects of the service which need to be improved and identify and implement appropriate changes in conjunction with the Clinical Lead
Participate with the Clinical Lead for the recruitment of employees in accordance with PCN Recruitment Policy and NHS Safer Recruitment Guidelines.
In conjunction with the Clinical Lead, work within the available budget of the service and attend regular Performance Management meetings
Work closely with and assist the Clinical Lead with development and implementation of operational / clinical policies contributing to the formulation and review of appropriate policies
Deliver training where appropriate for other professionals
Assist the Team in the evaluation and monitoring of service in conjunction with the Clinical Lead, Clinical Director and PCN Manager
Ensure that the service through the implementation of performance management, all key performance indicators and targets identified by the PCN are met, and adhere to local and government initiatives
Responsible for the coordination and management of the team in providing a safe, effective and holistic clinical service, ensuring the delivery of high quality care packages
Person Specification
Qualifications
Essential
- Educated to NVQ level 2 in Heath and social care in a relevant subject or equivalent level of qualification or significant equivalent previous proven experience
- Excellent knowledge of IT systems and software programmes such as Microsoft Outlook, Word, Excel, PowerPoint, MS Teams. In addition, experience of using a range of platforms for promotion content creation.
- Qualified to NVQ level 3
- Qualified in phlebotomy
- Demonstrable experience in dealing with the public and dealing with sensitive and confidential information.
- Knowledge of identifying patients from clinical systems, contacting patients and organising appointments, transport for patients who require
- A good understanding of the objectives and challenges of the PCN pilot
Desirable
- Experience of working as an HCA or care coordinator.
- Ability to assess when cases need to be escalated, stepped down or transitioned to another service, due to safeguarding or parenting capacity concerns, significant changes in need or reaching transition age
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