The closing date is 3rd September 2024

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, 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 patients 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 Teesdale PCN team to support the patients of up to 6 GP practices.

Main duties of the job

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

Proactively identify patients who require care coordination, using agreed criteria and population 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 address wider determinants of health. Help patients manage their needs through answering queries, making and managing appointments.

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 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. Safety netting two week wait referrals

Coordinating and following up of referrals

Coordinating GSF, safeguarding, and MDT meetings. 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.

About us

A group of 12 GP practices across Durham Dales got together, looking for a solution to help them provide the care patients needed, share resources and ideas, and be prepared for the challenges the NHS would face in the future. The answer they came up with was a formal collaboration between the dozen practices: the Durham Dales Health Federation. DDHFs founding principal is to work together to provide high-quality, cost effective primary healthcare services. That means providing a range of services that all GP practices in the area can use to help look after patients. We employ a range of clinical staff pharmacists, dispensers, nurses, emergency care practitioners and social prescribing link workers as well as non-clinical, administration support staff.

Benefits DDHF can offer; paid mileage. NHS pension. A car lease scheme which is transferable. We fully support training & development. Regular 1-2-1 support & appraisal. Cycle to work Scheme (salary sacrifice bike). Complimentary refreshments. Free Car Park, Health service discounts, Immunisations offered, Eye tests reimbursed.

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