Bishop Auckland PCN Care Coordinator

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, and patients 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 patient’s pathway, expedite care where appropriate, and follow up letters and results.

You will support the practice to deliver good quality care for frail patients, patients in palliative care, and patients with long term conditions. You will work with the practice team to prepare for effective GSF and frailty meetings, and ensure that processes such as falls assessments 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 will support the practice to ensure that patients are reviewed at an appropriate frequency, and to achieve QOF, IIF, and LIAISE targets.

You will be working as part of the Bishop Auckland PCN team to support the patients of up to 3 GP practices

Work with practice teams to coordinate care for patients with greater needs, to improve the patient pathway and expedite care as appropriate

Proactively identify patients who require care coordination, using agreed criteria and population health tools as appropriate

Support the delivery of the practice GSF and frailty programmes

Support the achievement of practice quality standards including QOF, IIF, and LIAISE

Work closely and in partnership with the Social Prescribing Link Workers,to address wider determinants of health, such as poor housing, debt, stress and loneliness and identify and prioritise a person's care/support needs in a single personalised care and support plan, based on what matters to the person in shared decision making process.

Help patients manage their needs through answering queries, making and managing appointments, and ensuring that people have access to good quality information about their care

Assist people to access personal health budgets where appropriate

Coordinate appointments and encourage uptake of vaccinations in eligible populations

Encouraging uptake of QOF LTC Annual and Structured Medication Reviews

Encouraging the delivery of good quality annual health checks for patients with learning 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. Safetynetting two week wait referrals

Coordinating and following up of referrals and appointments

Coordinating GSF, safeguarding, and MDT meetings, and follow up actions. Work with these patients and other groups as identified by the Practice to help with timely care navigation and coordination across primary & secondary health and social care services. Share decision aids such as information on Vaccines, Cancer, Personal health budgets, frailty, Macmillan, Join the dots, CAB, Care connect, Stop smoking, Drug & alcohol services, Talking changes.

Job Type: Full-time

Salary: £22,836.00 per year

Benefits:

• Casual dress
• Company pension
• Cycle to work scheme
• Employee discount
• Free or subsidised travel
• Free parking
• On-site parking
• Store discount

Schedule:

• Day shift
• Monday to Friday

Work Location: In person

Application deadline: 24/02/2023
Reference ID: Bishop Auckland CC