Multi-Disciplinary Teams

• Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
• Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary, this includes co-ordination of GSF meetings, ensuring that all attendees are notified of meetings and taking of meeting notes.
• Manage reporting required and associated within the DES specifications for required services.
• To act as administrative support to the practice safeguarding lead, ensuring that correspondence relations to those subject to safeguarding arrangements (children and adults) is passed to the safeguarding lead as necessary and relevant coding is done.
• Act as a point of contact for care homes and key contacts in supported living establishments when arranging annual reviews etc. and coordinating access for GP’s to administer influenza vaccinations as required.

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.
• Clinical coding for updating patient records from discharge information with follow up to be applied if necessary.
• Triaging of patients request for appointments.
• 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.
• Act as a point of contact for relatives of deceased patients, ensuring they are kept informed regarding issuing and forwarding of death certificates or updating on referrals to the coroner.
• Support the operation of the Patient Participation Group within the practice.
• Assist in directing patients whose first language is not English, ensuring information is available to them or signposting them to appropriate services.

Maintenance of IT based information systems and responsibility for key performance data:

• To ensure the IT requirements for recording activity are adhered to in collaboration with other team members.
• Accurate update and maintenance of GP systems within the MDT.
• To provide agreed performance/activity data within the MDT and PCN and wider OHP organisation.

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 both within and outside the PCN or group of PCNs.
• Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, GPA’s other practice staff and other healthcare professionals including social prescribing link workers, 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 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 in-reach specialists.
• Meet regularly with the clinical lead and review case load and MDT function.
• Keep the MDT and OHP organisation abreast of ‘good news’ stories.
• Provide background information about individuals for the weekly MDT meetings.
• Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public.
• Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT.

Other responsibilities

• To act at all times in an anti-discriminatory manner.
• To be able to plan and respond to workload according to operational priorities.
• To support the delivery of these functions across wider locality areas where necessary.
• To undertake any training required in order to maintain competency including mandatory training.
• To contribute to, and work within a safe working environment.
• The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practice’s equal opportunity policies and procedures.
• The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.
• The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.
• To ensure practice information regarding external agencies is kept up to date and other practice staff are fully aware.
• Supporting patients to use digital technology including use of the NHS App.

Patient Care

• Communicate effectively and sensitively and use language appropriate to a patient and carer/relative’s condition and level of understanding.
• Effectively use all methods of communication and be aware of and manage barriers to communication.
• Effectively recognise and manage challenging behaviours, carers and or relatives.
• Provide information to patients, their carers and/or relatives on behalf of the team.

Supporting Care Delivery

• Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated.
• Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.
• Follow through with service users and others involved to ensure all services and care arrangements are in place.

Autonomy/Scope within Role

• The post holder will be required to work within clearly defined organisational protocols, policies and procedures.

Key Relationships

Key Working Relationships Internal:

• Clinical Lead for the MDT
• GPs and General practice teams within the Practice/PCN
• PCN Clinical Director / PCN Manager/s
• GPs, Practice Managers, GPA’s and General practice teams within the PCN
• MDT members including but not exhaustive: Clinical Pharmacists, Technicians, Physician Associates, Physios, Paramedics, Social Prescribing Link Workers

Key Working Relationships External:

• GPs from neighbouring PCNs
• Service providers
• Social care
• Voluntary services
• Patients/service users
• Carers/relatives

Health and Safety/Risk Management

• The post-holder must comply at all times with the organisation and Practice’s Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisation’s Incident Reporting System.
• The post-holder will comply with the Data Protection Act (1984), The General Data Protection Regulations (2018) and the Access to Health Records Act (1990).
• The post-holder will comply with all necessary training requirements relevant to the role as identified by the organisation.

Equality and Diversity

• The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc.

Respect for Patient Confidentiality

• The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.

Special Working Conditions

• The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies.

Job Description Agreement

This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive.  It will be subject to regular review and amendment as necessary in consultation with the post holder.