An exciting opportunity has arisen to recruit an additional Care Coordinator at Lakeside Healthcare at St Neots PCN.
The care coordinator role has become a crucial part of General Practice in the last few years. This role is multi-faceted, allowing the successful applicant to have a varied and interesting balance at work.
Care coordinators provide extra time, capacity, and expertise to support patients in preparing for or in following up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the practice to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
This might involve working with a variety of patient groups who are identified as being vulnerable such as the elderly, housebound, people with frailty, patients with physical disability, learning disability, chronic physical health problems, patients with cancer, or those with drug or alcohol misuse. This can be an extremely rewarding opportunity to make a big difference in people's lives and be the link point to avoid patients having fragmented care.
Main duties of the job
You will work closely with the patient and their clinician to coordinate patient healthcare and direct them to the appropriate service to ensure that they get the most suitable care. You will: Be involved in care navigation from reception to optimize patient flow. Be involved working with specific vulnerable patient groups to optimize their care. This job is ideal for someone with initiative and the drive to see through their own ideas and projects. Bring together all of a person's identified care and support needs, and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice. Help people to manage their needs, answering their queries and supporting them to make appointments. Support people to take up education, training, and/or employment, and to access appropriate benefits where eligible. Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision-making conversation. Ensure that people have good quality information to help them make choices about their care. Explore and assist people to access personal health budgets where appropriate. Support the coordination and delivery of Multi-Discipline Teams within PCNs. Support the management of referrals received through the NHS App to the practice and direct to the appropriate clinician or professional group. About us
LAKESIDE HEALTHCARE
is changing the face of primary care provision in England. We are bold, adventurous, and ambitious and determined to thrive in uncertain times. We are the largest true partnership in the NHS and operate from various sites across the East Midlands. We serve the healthcare needs of over 170,000 patients across Northamptonshire, Lincolnshire & Cambridgeshire. Caring & Respect:
Simply put we genuinely care about people: working together for our patients and our teams, our patients come first in everything we do. Teamwork & Quality:
In all areas of our business we network, collaborate and learn from our Patients, Stakeholders and each another to ensure we are always striving to improve, making the right and best decisions to provide the best service. About the Practice/Department/Team
St Neots PCN is an average sized yet forward-thinking Primary Care Network (PCN) comprising of three practices within central St Neots and Great Staughton. We have built and developed a growing pharmacy team and recognise the value that these roles will bring to our practices and our patients; we now look forward to growing our PCN team. You will be joining an established, dynamic and varied team, whose aim is to provide exemplary patient care; finding innovative solutions in general practice to deliver the best care we can to our patients. Job responsibilities
Care coordinators provide extra time, capacity, and expertise to support patients in preparing for or in following up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the PCN to better identify and manage a caseload of selected patients making sure that appropriate support is made available to them and their carers and ensuring that their changing needs are addressed. They focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification, this will include support digital referral management, for example from the NHS App. You will have a background in healthcare coordination, an understanding of projects and population health initiatives. In this role, you will be responsible for managing and coordinating care services, collaborating with multidisciplinary teams, and implementing processes to improve health outcomes for specific populations. You will play a crucial role in the success of our population health project and contribute to enhancing the overall well-being of our community. Key responsibilities and tasks You will: Support and contribute to the population health project. Collect, analyse and interpret data related to population health, identifying trends, gaps in care and areas for improvement. Support project plans, timelines and milestones to ensure the successful execution of population health initiatives. Maintain accurate and up to date records of patient interactions, interventions, and outcomes, and generate reports to monitor project progress and outcomes. Stay informed about the latest developments in population health and apply this knowledge to improve project effectiveness. Proactively identify and work with a cohort of people to support their personalised care requirements, ensuring an understanding of what matters to them. Bring together all of a person's identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice. Help people to manage their needs, answering their queries and supporting them to make appointments. Support people to take up training and employment, and to access appropriate benefits where eligible. Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision making conversation. Ensure that people have good quality information to help them make choices about their care. Support people to understand their level of knowledge, skills and confidence their Activation level when engaging with their health and wellbeing, including through use of the Patient Activation Measure. 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. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. Support the coordination and delivery of Multi Discipline Teams within PCNs. Support the management of referrals received through the NHS App to the practice and direct to the appropriate clinician or professional group. Liaise with members across all practices within the PCN, supporting good communication. Refer through to the appropriate member of the team, and/or make referrals on behalf of the team. Support the co-ordination and delivery of multidisciplinary teams (MDTs) within the PCN, to include management and arrangement planning of team meetings and producing reports as requested. Visit patients in community, home or care home setting to assess and discuss their care needs involving carers, as appropriate. Establish good working relationships with people employed in practices across the PCN to enable them to carry out their duties effectively. It is important that the skills of existing teams continue to be valued and their roles developed as agreed with the practice. Training requirements:
The Personalised Care Institute will set out what training is available and expected for Care Coordinators. Other
Be willing to undertake travel to various locations to carry out duties of the post as required. To safeguard the health, well-being, and safety of the patients we work with, some of whom may be classed as vulnerable people or adults at risk. In the event of a risk to a Patient becoming apparent or if concerns arise about a vulnerable person's welfare, to immediately report these concerns in line with the appropriate policy and procedure. NB. In addition to these responsibilities, employees are required to carry out other duties as may be reasonably required. Lakeside Healthcare reserves the right to vary this job description from time to time in line with business needs. Person Specification
Experience
Experience coordinating with multiple stakeholders or individuals to meet specified outcomes. Experience providing advice/signposting. Experience of data collection and providing monitoring information to assess the impact of services. Experience of partnership/collaborative working and of building relationships across a variety of organisations including the voluntary sector. Experience of working with healthcare professionals and/or previous experience in the NHS or social care. Experience of using clinical systems such as System One. Experience of supporting people. Experience of supporting service improvement. Qualifications
NVQ Level 3 or equivalent and/or relevant basic/first level professional qualification or working towards this. Good level of education with GCSE Math and English Grade C or above or equivalent. 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.
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You will work closely with the patient and their clinician to coordinate patient healthcare and direct them to the appropriate service to ensure that they get the most suitable care. You will: Be involved in care navigation from reception to optimize patient flow. Be involved working with specific vulnerable patient groups to optimize their care. This job is ideal for someone with initiative and the drive to see through their own ideas and projects. Bring together all of a person's identified care and support needs, and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice. Help people to manage their needs, answering their queries and supporting them to make appointments. Support people to take up education, training, and/or employment, and to access appropriate benefits where eligible. Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision-making conversation. Ensure that people have good quality information to help them make choices about their care. Explore and assist people to access personal health budgets where appropriate. Support the coordination and delivery of Multi-Discipline Teams within PCNs. Support the management of referrals received through the NHS App to the practice and direct to the appropriate clinician or professional group. About us
LAKESIDE HEALTHCARE
is changing the face of primary care provision in England. We are bold, adventurous, and ambitious and determined to thrive in uncertain times. We are the largest true partnership in the NHS and operate from various sites across the East Midlands. We serve the healthcare needs of over 170,000 patients across Northamptonshire, Lincolnshire & Cambridgeshire. Caring & Respect:
Simply put we genuinely care about people: working together for our patients and our teams, our patients come first in everything we do. Teamwork & Quality:
In all areas of our business we network, collaborate and learn from our Patients, Stakeholders and each another to ensure we are always striving to improve, making the right and best decisions to provide the best service. About the Practice/Department/Team
St Neots PCN is an average sized yet forward-thinking Primary Care Network (PCN) comprising of three practices within central St Neots and Great Staughton. We have built and developed a growing pharmacy team and recognise the value that these roles will bring to our practices and our patients; we now look forward to growing our PCN team. You will be joining an established, dynamic and varied team, whose aim is to provide exemplary patient care; finding innovative solutions in general practice to deliver the best care we can to our patients. Job responsibilities
Care coordinators provide extra time, capacity, and expertise to support patients in preparing for or in following up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the PCN to better identify and manage a caseload of selected patients making sure that appropriate support is made available to them and their carers and ensuring that their changing needs are addressed. They focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification, this will include support digital referral management, for example from the NHS App. You will have a background in healthcare coordination, an understanding of projects and population health initiatives. In this role, you will be responsible for managing and coordinating care services, collaborating with multidisciplinary teams, and implementing processes to improve health outcomes for specific populations. You will play a crucial role in the success of our population health project and contribute to enhancing the overall well-being of our community. Key responsibilities and tasks You will: Support and contribute to the population health project. Collect, analyse and interpret data related to population health, identifying trends, gaps in care and areas for improvement. Support project plans, timelines and milestones to ensure the successful execution of population health initiatives. Maintain accurate and up to date records of patient interactions, interventions, and outcomes, and generate reports to monitor project progress and outcomes. Stay informed about the latest developments in population health and apply this knowledge to improve project effectiveness. Proactively identify and work with a cohort of people to support their personalised care requirements, ensuring an understanding of what matters to them. Bring together all of a person's identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice. Help people to manage their needs, answering their queries and supporting them to make appointments. Support people to take up training and employment, and to access appropriate benefits where eligible. Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision making conversation. Ensure that people have good quality information to help them make choices about their care. Support people to understand their level of knowledge, skills and confidence their Activation level when engaging with their health and wellbeing, including through use of the Patient Activation Measure. 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. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. Support the coordination and delivery of Multi Discipline Teams within PCNs. Support the management of referrals received through the NHS App to the practice and direct to the appropriate clinician or professional group. Liaise with members across all practices within the PCN, supporting good communication. Refer through to the appropriate member of the team, and/or make referrals on behalf of the team. Support the co-ordination and delivery of multidisciplinary teams (MDTs) within the PCN, to include management and arrangement planning of team meetings and producing reports as requested. Visit patients in community, home or care home setting to assess and discuss their care needs involving carers, as appropriate. Establish good working relationships with people employed in practices across the PCN to enable them to carry out their duties effectively. It is important that the skills of existing teams continue to be valued and their roles developed as agreed with the practice. Training requirements:
The Personalised Care Institute will set out what training is available and expected for Care Coordinators. Other
Be willing to undertake travel to various locations to carry out duties of the post as required. To safeguard the health, well-being, and safety of the patients we work with, some of whom may be classed as vulnerable people or adults at risk. In the event of a risk to a Patient becoming apparent or if concerns arise about a vulnerable person's welfare, to immediately report these concerns in line with the appropriate policy and procedure. NB. In addition to these responsibilities, employees are required to carry out other duties as may be reasonably required. Lakeside Healthcare reserves the right to vary this job description from time to time in line with business needs. Person Specification
Experience
Experience coordinating with multiple stakeholders or individuals to meet specified outcomes. Experience providing advice/signposting. Experience of data collection and providing monitoring information to assess the impact of services. Experience of partnership/collaborative working and of building relationships across a variety of organisations including the voluntary sector. Experience of working with healthcare professionals and/or previous experience in the NHS or social care. Experience of using clinical systems such as System One. Experience of supporting people. Experience of supporting service improvement. Qualifications
NVQ Level 3 or equivalent and/or relevant basic/first level professional qualification or working towards this. Good level of education with GCSE Math and English Grade C or above or equivalent. 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.
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