Teesdale Care Co-Ordinator

Job summary You will work with GP practice teams to coordinate the care of patients with frailty, cancer,long term conditions, safeguarding and social issues, patients requiring proactive care, andpatients who require support to communicate effectively.
You will liaise with the patient,practice team, secondary care teams, social services, the voluntary and community sector,and other members of the Primary Care Network team to help smooth the patientspathway, expedite care where appropriate, and follow up letters and results.You will support the practice to deliver good quality care for frail patients, patients inpalliative care, and patients with long term conditions.
You will work with the practice teamto prepare for effective GSF and frailty meetings, and ensure that processes such as fallsassessments and medication reviews are carried out in a timely manner.
Where appropriate,you will help develop a personalised care and support plan for these patients.
You willsupport the practice to ensure that patients are reviewed at an appropriate frequency, andto achieve QOF, IIF, and LIAISE targets.You will be working as part of the Teesdale PCN team to support the patients of up to 6 GPpractices.
Main duties of the job Part time; hours.Work with practice teams to coordinate care for patients with greater needs, toimprove the patient pathway and expedite care Proactively identify patients who require care coordination, using agreed criteria andpopulation health tools Support the achievement of practice quality standards including QOF, IIF, and LIAISE Work closely and in partnership with the Social Prescribing Link Workers, to addresswider determinants of health.
Help patients manage their needs through answering queries, making and managingappointments.
Assist people to access personal health budgets Encouraging uptake of QOF LTC Annual and Structured Medication Reviews Encouraging the delivery of good quality annual health checks for patients withlearning disabilities and SMI.
Supporting the practice in delivering its IIF priorities Supporting cancer screening, including FIT tests/bowel screening, cervical screening,and breast screening.
Refer smokers to smoking cessation.
Safety netting two weekwait referrals Coordinating and following up of referrals Coordinating GSF, safeguarding, and MDT meetings.
Work withthese patients and other groups as identified by the Practice to help with timely carenavigation and coordination across primary & secondary health and social careservices.
Share decision aids such as information on Vaccines, Cancer, Personal healthbudgets, frailty, Macmillan, Join the dots, CAB, Care connect, Stop smoking, Drug &alcohol services, Talking changes.
About us A group of 12 GPpractices across Durham Dales got together, looking for a solution to help themprovide the care patients needed, share resources and ideas, and be preparedfor the challenges the NHS would face in the future.
The answer they came upwith was a formal collaboration between the dozen practices: the Durham DalesHealth Federation.
DDHFs founding principal is to work together to providehigh-quality, cost effective primary healthcare services.
That means providinga range of services that all GP practices in the area can use to help lookafter patients.
We employ a range of clinical staff pharmacists, dispensers,nurses, emergency care practitioners and social prescribing link workers aswell as non-clinical, administration support staff.Benefits DDHF canoffer; paid mileage.
NHS pension.
A car lease scheme which is transferable.
Wefully support training & development.
Regular 1-2-1 support &appraisal.
Cycle to work Scheme (salary sacrifice bike).
Complimentary refreshments.
Free Car Park, Healthservice discounts, Immunisations offered, Eye tests reimbursed.
Job description Job responsibilities Job responsibilitiesWork with practiceteams to coordinate care for patients with greater needs, to improve thepatient pathway and expedite care as appropriateProactivelyidentify patients who require care coordination, using agreed criteria andpopulation health tools as appropriateSupport thedelivery of the practice GSF and frailty programmesSupport theachievement of practice quality standards including QOF, IIF, and LIAISEWork closely and inpartnership with the Teesdale Social Prescribing Link Workers, to assistpatients to take up training and employment and access benefitsHelp patientsmanage their needs through answering queries, making and managing appointments,and ensuring that people have access to good quality information about theircareAssist people toaccess personal health budgets where appropriateCoordinateappointments and encourage uptake of vaccinations in eligible populationsUtilise anddemonstrate sensitive communication styles, to ensure patients are fullyinformed and consent to treatmentSupport patients touse decision aids in preparation for shared decision making conversationsCommunicateeffectively with patients and carers, recognising the need for alternativemethods of communication to overcome different levels of understanding,cultural background and preferred ways of communicatingAnticipate barriersto communication and take action to improve communicationMaintain effectivecommunication within the PCN and with external stakeholders Person Specification Experience Essential Experience of providing and receiving complex, sensitive information Desirable Experience working in a primary care setting Qualifications Essential GCSE Grade A-C in Maths & English or skills level 2 Maths & English or equivalent Desirable Qualification in a health or social care allied profession Knowledge & Skills Essential Demonstrate an appreciation of the health needs of patients in the Teesdale area Communication skills, both written and verbal Empathy with the patients needs and conditions Positive attitude to work, colleagues and patients Non-judgemental attitude to patients Tact and diplomacy Desire to help and put people first Ability to negotiate the best possible services for patients Advocacy skills Time management Team working Good IT keyboard skills Desirable Knowledge of community based primary care issues Knowledge of primary care networks and collaborative ways of working Understanding of safeguarding principles.
Knowledge of SystmOne information system Other Essential Full UK driving Licence Willingness to travel between GP practices and work from various locations in the Dales area Highly motivated Enthusiastic and confident