Care Coordinator - Kettering, United Kingdom - Linden Medical Group

Description

Linden Medical Group


Job Title:

Care Coordinator


Responsible to:

Practice Manager


Accountable to:

Practice Manager


Salary:

£11.00 per hr


Hours:

32 hours pw, Mon to Fri


Location:

Linden Medical Centre


Duties and Responsibilities

The Care Coordinator will be employed by the Practice, but will also be part of the Primary Care Network (PCN) Multi-Disciplinary Team (MDT) who are responsible for managing the care of people registered with practices within Red Kite.

This will involve coordinating the work of healthcare professionals and non-clinical staff involved in the care of service users registered at GP practices within the wider PCN population

A key part of the role of a care coordinator is in the Care Homes and Frailty


MDT:

improving the continuity of care by acting as a point of contact for residents, families and professionals who visit care homes and frail patients, such as MDT members and in-reach specialists.

This may include virtual home rounds and associated support.

The role will be to support the PCN and Practice priorities and may include reviewing and updating patients records, running reports from clinical systems, having input to other clinical meetings (for example palliative care).

Other clinical responsibilities may be developed over time based on the needs of practices and the PCN. A degree of flexibility is essential for this role.


Primary Duties and Areas of Responsibility

PCN

• To work with the PCN Manager to ensure good communication links are established and maintained between the PCN and Practice staff.
• To ensure that care records are coded to optimize practice income (e.g. Learning Disability Checks, CVD reviews, Flu Vaccinations, Ethnicity recording etc.)
• To use Arden's reports to identify patients who need to be seen to meet the IIF targets (e.g LD Health checks/ethnicity/BP monitoring etc.)
• To work with the PCN manager to support implementation of the DES/IIF and to agree a work plan on the areas the practice needs to develop.
• Liaise with Community Workers at PCN level to ensure that their services are known to the practice and patients are getting the benefit of those services
• 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 weekly MDT meetings.
• Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT.

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 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.
• Attend palliative care and age well meetings.

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 across practices 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, care home managers 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 community services, 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 inreach specialists.
• Meet regularly with the clinical lead and review case load and MDT function.
• Provide background information about individuals for the weekly MDT meetings
• Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT

When Required:

• Undertake practice administrative tasks such as, scanning, referrals, notes summarizing, recalls and other admin duties as necessary.
• Ensure patients are coded correctly e.g. housebound, lives in care home.

Other responsibilities

• To act at all times in an antidiscriminatory manner
• To be able to plan and respond to workload according to operational priorities
• To under