Battersea Primary Care Network rO6B9TFO
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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 work closely with GPs, nurses and other primary care professionals within the PCN to identify and manage a caseload of 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 for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.
In addition for this role, the Care Coodinator will work for up to 1 day a week supporting the work of the Youth Clinic.
We also have a second Care Coordinator role available for 1 year maternity cover, with the possibility of extending. This role does not have any Youth Clinic involvement.
The main responsibilities of the role include:
- Managing a caseload of identified patients with complex care needs, supporting their clinical needs by helping arrange clinical appointments and reviews, responding to queries, signposting to appropriate services and liaising with secondary care and other health services
- Proactively identify and work with a cohort of patients to support their personalised care needs
- Ensure patient have acurate and appropriate information to help them make choices about their care
- Support practice recall systems, calling patients, booking appointments, chasing DNAs
- Ensure patient records are up-to-date, working at all times within GDPR and confidentiality policies
- Support the Youth clinic by attending case-based discussion meetings and taking minutes, update spreadsheets with patients lists, maintain accurate safeguarding records, book patient appointments and write newsletters,
Battersea Primary Care Network
Ltd
Care Coordinator
Main Responsibilities
:
These may vary according to the current needs and priorities of the GP practices/PCN teams but may include any or all of the following:
1.Plan and carry out patient call and recall systems for public health programmes
(eg Covid vaccine programme, child immunisations, cervical screening), focusing particularly on vulnerable and hard to reach groups and patients with complex care needs
2.Setting up and running clinical searches in order to monitor and focus care of target groups
3.Manage a caseload of identified patients with complex care needs, supporting them and their clinical teams by:
coordinating their medical care when required
responding to queries and requests for assistance
sign-posting patients and carers to appropriate support services
working with clinicians to ensure all the contractual requirements for patients with complex care needs are met
assisting in the administration of MDT meetings and coordinating actions identified during these meetings
Care and Support Planning
Provide organisational and operational support for the setup of COVID vaccination clinics and other public health initiatives
Proactively identify and work with a cohort of people to support their personalised care requirements
Help people to manage their needs, answering their queries and supporting them to make and get to appointments.
Raise awareness of shared decision making and decision support tools and assist people to have shared decision-making conversations with their healthcare teams.
Ensure that people have good quality information to help them make choices about their care
Bring together a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with person centred service plan (PCSP) best practice
Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
Support the coordination and delivery of MDTs within PCNs.
Youth Clinic Care Coordination
- Attending the case based discussion meetings twice a month on a Thursday (one face to face, one virtual)
- On the other Thursdays attending the online meetings with Clinical lead and Clinical Associate Psychologist to run through cases.
- To look after and update the spreadsheet with all of the youth clinic patients on it, liaising with the CAP and social prescribers
- To keep minutes from the cased based discussion meetings
- To collate, store and chase up all of the safeguarding forms and ensure the safeguarding spreadsheet is up to date
- Help CAP or the social prescribers to arrange appointments with young people or assist in arranging/co-ordinating MDT meetings with CAMHS/Schools etc when needed around complex cases
- To produce a one page quarterly newsletter with figures and some 'good news case studies' from the last 3 months and send it out to all practices. This will involve liaising with the whole team as well as Enable to get the data. It will also involved creating a database to ensure we are proactive in collecting data all the time so we can produce these rolling reports including things like satisfaction scores from social prescribers.
- Assist with sending out texts to patients when they have completed their time with the clinic in the form of a questionnaire
- Setting up appointments with families/young people with myself if they need to speak to a GP outside of their normal practice.
Clinical System / Medical Records
Ensure total familiarity with the clinical system;
Book appointments and recalls ensuring sufficient information is recorded;
Code and extract data from clinical correspondence and input into EMIS Electronic Patient Record
Run searches and produce reports as required with the support of practice IT teams
Ensure correspondence, reports, results etc. are dealt with in a timely manner as per practice protocol
Shared responsibility for target group disease register with clinical teams
Telephone System
Receive and make calls as required answering any queries that arise
Divert calls and take messages as appropriate ensuring accuracy
Other responsibilities
Towork at all times within the requirements of GDPR, maintaining patient confidentiality
Maintain accurate clinical records at all times
To participate in educational events as advised by the Practice
To attend various Practice meetings as requested
Any other tasks that may be required by the practice from time to time
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 work closely with GPs, nurses and other primary care professionals within the PCN to identify and manage a caseload of 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 for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.
In addition for this role, the Care Coodinator will work for up to 1 day a week supporting the work of the Youth Clinic.
We also have a second Care Coordinator role available for 1 year maternity cover, with the possibility of extending. This role does not have any Youth Clinic involvement.
The main responsibilities of the role include:
- Managing a caseload of identified patients with complex care needs, supporting their clinical needs by helping arrange clinical appointments and reviews, responding to queries, signposting to appropriate services and liaising with secondary care and other health services
- Proactively identify and work with a cohort of patients to support their personalised care needs
- Ensure patient have acurate and appropriate information to help them make choices about their care
- Support practice recall systems, calling patients, booking appointments, chasing DNAs
- Ensure patient records are up-to-date, working at all times within GDPR and confidentiality policies
- Support the Youth clinic by attending case-based discussion meetings and taking minutes, update spreadsheets with patients lists, maintain accurate safeguarding records, book patient appointments and write newsletters,
About us
Battersea Primary Care Network
Ltd
Care Coordinator
Main Responsibilities
:
These may vary according to the current needs and priorities of the GP practices/PCN teams but may include any or all of the following:
1.Plan and carry out patient call and recall systems for public health programmes
(eg Covid vaccine programme, child immunisations, cervical screening), focusing particularly on vulnerable and hard to reach groups and patients with complex care needs
2.Setting up and running clinical searches in order to monitor and focus care of target groups
3.Manage a caseload of identified patients with complex care needs, supporting them and their clinical teams by:
coordinating their medical care when required
responding to queries and requests for assistance
sign-posting patients and carers to appropriate support services
working with clinicians to ensure all the contractual requirements for patients with complex care needs are met
assisting in the administration of MDT meetings and coordinating actions identified during these meetings
Care and Support Planning
Provide organisational and operational support for the setup of COVID vaccination clinics and other public health initiatives
Proactively identify and work with a cohort of people to support their personalised care requirements
Help people to manage their needs, answering their queries and supporting them to make and get to appointments.
Raise awareness of shared decision making and decision support tools and assist people to have shared decision-making conversations with their healthcare teams.
Ensure that people have good quality information to help them make choices about their care
Bring together a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with person centred service plan (PCSP) best practice
Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
Support the coordination and delivery of MDTs within PCNs.
Youth Clinic Care Coordination
- Attending the case based discussion meetings twice a month on a Thursday (one face to face, one virtual)
- On the other Thursdays attending the online meetings with Clinical lead and Clinical Associate Psychologist to run through cases.
- To look after and update the spreadsheet with all of the youth clinic patients on it, liaising with the CAP and social prescribers
- To keep minutes from the cased based discussion meetings
- To collate, store and chase up all of the safeguarding forms and ensure the safeguarding spreadsheet is up to date
- Help CAP or the social prescribers to arrange appointments with young people or assist in arranging/co-ordinating MDT meetings with CAMHS/Schools etc when needed around complex cases
- To produce a one page quarterly newsletter with figures and some 'good news case studies' from the last 3 months and send it out to all practices. This will involve liaising with the whole team as well as Enable to get the data. It will also involved creating a database to ensure we are proactive in collecting data all the time so we can produce these rolling reports including things like satisfaction scores from social prescribers.
- Assist with sending out texts to patients when they have completed their time with the clinic in the form of a questionnaire
- Setting up appointments with families/young people with myself if they need to speak to a GP outside of their normal practice.
Clinical System / Medical Records
Ensure total familiarity with the clinical system;
Book appointments and recalls ensuring sufficient information is recorded;
Code and extract data from clinical correspondence and input into EMIS Electronic Patient Record
Run searches and produce reports as required with the support of practice IT teams
Ensure correspondence, reports, results etc. are dealt with in a timely manner as per practice protocol
Shared responsibility for target group disease register with clinical teams
Telephone System
Receive and make calls as required answering any queries that arise
Divert calls and take messages as appropriate ensuring accuracy
Other responsibilities
Towork at all times within the requirements of GDPR, maintaining patient confidentiality
Maintain accurate clinical records at all times
To participate in educational events as advised by the Practice
To attend various Practice meetings as requested
Any other tasks that may be required by the practice from time to time
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