PCN Care Co-ordinator Data Analyst for QoF and Research

Job summary

The PCN QOF, Research & Care Coordination Data Analyst is a non-clinical role that combines data analysis, quality improvement, research support, population health management and care coordination within Wellington Medical Centre and Taunton Deane West Primary Care Network (PCN). The role supports the practice in improving patient outcomes through the effective use of clinical data, identifying patients who may benefit from proactive interventions, and contributing to high-quality, patient-centred care.

Wellington Medical Centre is part of Taunton Deane West PCN, which brings together GPs, nurses, pharmacists, social prescribing link workers, health and wellbeing coaches and other healthcare professionals to provide integrated care for local communities. The PCN is committed to improving health outcomes, reducing inequalities and delivering proactive, coordinated services. Research, innovation and continuous improvement are key priorities, with staff encouraged to contribute to service development and professional growth. The role offers some flexible working and provides an opportunity to make a meaningful contribution to both patient care and the ongoing development of primary care services

Main duties of the job

Key responsibilities include supporting Quality and Outcomes Framework (QOF) performance through clinical searches, audits, reporting and data analysis, enabling the practice to monitor achievement, identify gaps in care and ensure patients receive timely reviews and interventions. Assisting to improving data quality and clinical coding by identifying inaccuracies, inconsistencies and missing information within patient records, helping to ensure that clinical data is accurate, reliable and meaningful for patient care, service planning and reporting.The role also uses population health data, risk stratification tools and clinical intelligence to identify patients who may require monitoring, follow-up or proactive support. This includes patients with long-term conditions, frailty, multiple health needs or those at risk of deterioration. Working closely with the practice and PCN Team and other members of the multidisciplinary team, the post holder helps coordinate care, facilitate referrals and support patients in accessing appropriate healthcare, community and voluntary sector services. The role contributes to research projects, service evaluations and quality improvement initiatives, using data and evidence to support better decision-making and improved patient outcomes. The post holder acts as an important link between data, healthcare professionals and patients, helping to deliver coordinated, proactive and personalised care across the practice and Primary Care Network

About us

Taunton Deane West Primary Care Network is an NHS collaboration between two GP practices Wellington Medical Centre and Lister House Partnership Our practice teams work closely together sharing expertise resources and ideas to develop new and innovative services that improve care for our local population

As an approved PCN Learning Organisation we are committed to creating a positive learning culture where both learners and educators are supported to develop their skills and thrive We value teamwork continuous improvement and the sharing of knowledge across our practices

Together we care for approximately 28000 registered patients across the two practices Our vision is to continue improving the quality and accessibility of care we provide by responding to the needs of our patient population and developing services that support better health outcomes

Being part of a Primary Care Network enables us to benefit from additional roles and expertise through the Additional Roles Reimbursement Scheme These roles strengthen our existing teams and help us provide the right care at the right time from the right professional

We are committed to delivering compassionate person centred care while working collaboratively with our patients our practices and our wider healthcare partners

Job description

Job responsibilities

A QOF and Primary Care Performance

Support Wellington Medical Centre with monitoring and improving QOF performance
Asist with regular clinical searches and data analysis to identify patients who meet QOF criteria or require clinical review
Produce accurate practice-level QOF reports dashboards and performance summaries
Assist with Identify missing incomplete or inaccurate clinical coding that may affect QOF achievement or patient care
Work with clinicians and administrative staff to improve clinical coding and data recording
Support QOF planning monitoring validation and year-end preparation
Maintain an up-to-date understanding of QOF requirements clinical coding and relevant primary care contractual requirements

B Data Analysis Clinical Searches and Population Health

Extract and analyse data from EMIS Web and other approved data sources
Undertake clinical searches to identify patients requiring reviews screening monitoring recalls follow-up or proactive intervention
Use practice data QOF information risk stratification and population health intelligence to identify patient groups with unmet health needs
Identify trends variations in care health inequalities and opportunities for earlier intervention
Support proactive management of patients at risk of deterioration hospital admission or loss to follow-up
Produce accurate reports dashboards and data summaries for clinical and management teams
Support clinical audits service evaluations and quality improvement projects
Provide data to support practice planning service development and decision-making
Monitor the outcomes of interventions and use data to assess their effectiveness
Ensure that data is accurate appropriately interpreted and presented in a clear and useful format

C Data Quality and Clinical Coding

Monitor the quality completeness and consistency of patient data
Identify missing inappropriate or inconsistent clinical coding
Work with Data quality Manager and administrative teams to improve the accuracy of patient records
Support the practice in maintaining high-quality consistent and appropriately coded clinical information
Develop and maintain data quality reports and action plans
Provide guidance to relevant staff on appropriate data entry and coding where required
Identify data quality issues that may affect QOF patient safety recalls research or service planning
Support standardisation of data collection and reporting within the practice

3 Care Coordination Navigation and Personalised Care

The post holder will undertake care coordination responsibilities appropriate to the role and in line with the PCN Care Coordinator ARRS requirements and local PCN arrangements

Patient Identification and Caseload Management

Use clinical searches QOF data population health information and risk stratification to identify patients who may benefit from proactive care coordination
Support the management of an appropriate caseload of patients particularly those with long-term conditions multiple health needs frailty complex needs or identified health and social care requirements
Work with GPs nurses and other members of the multidisciplinary team to identify appropriate patients for care coordination
Maintain accurate records of patient contacts interventions referrals care plans and outcomes
Regularly review caseloads and escalate changes in patient needs to the appropriate clinician or MDT member

Care Navigation and Coordination

Act as a point of contact for identified patients and help them understand and navigate available health social care and community services
Support patients to access appropriate services including primary care community services secondary care social prescribing voluntary and community organisations and other PCN services
Make appropriate referrals and coordinate communication between services
Support patients before and after appointments by helping them understand agreed actions and access appropriate follow-up
Assist with arranging appointments and other services where appropriate
Follow up patients to establish whether referrals agreed actions or services have been accessed
Identify barriers to accessing care and work with patients and relevant professionals to address these where possible
Escalate clinical safeguarding or other concerns promptly to an appropriate clinician

Personalised Care and Support

Support personalised care and support planning in collaboration with patients and the wider MDT
Use personalised conversations to understand what matters to patients including their health wellbeing social circumstances and personal goals
Encourage patients to participate actively in decisions about their care
Support patients to identify realistic health and wellbeing goals
Encourage self-management and access to appropriate health and wellbeing resources
Signpost or refer patients to social prescribing health and wellbeing coaching and other community support where appropriate
Promote patient independence choice and involvement in their care
Support carers and families where appropriate and within the scope of the role
Contribute to reducing health inequalities by identifying barriers to care and supporting appropriate solutions

4 Multidisciplinary Team Working

Work as an integral member of the practice and PCN multidisciplinary team
Contribute relevant patient population health and data intelligence
Coordinate and follow up actions arising from MDT discussions
Facilitate communication between patients clinicians practice staff PCN staff community services social care and other organisations
Work collaboratively with GPs practice nurses clinical pharmacists Social Prescribing Link Workers Health and Wellbeing Coaches and other ARRS roles
Develop effective working relationships with statutory voluntary community and social care organisations
Ensure relevant information is communicated appropriately between professionals involved in a patient's care
Contribute to a coordinated patient-centred approach to care

5 Research and Research Data

Support approved research studies undertaken through Wellington Medical Centre and the PCN
Identify potentially eligible patients using approved clinical searches and study criteria
Support appropriate patient identification and recruitment in accordance with research protocols
Undertake data searches collection validation and monitoring for approved research projects
Maintain accurate research databases spreadsheets and study documentation
Prepare anonymised or appropriately pseudonymised information where authorised and required
Support patient follow-up for approved research studies where appropriate
Monitor research recruitment data collection and project progress
Liaise with authorised research organisations research networks and other relevant stakeholders
Ensure research data is handled in accordance with study protocols approvals confidentiality requirements and information governance procedures
Support research findings to inform audit quality improvement and service development where appropriate

6 Audit Quality Improvement and Service Development

Use data and research findings to identify opportunities for improvement
Contribute to quality improvement initiatives and evaluation of new services or pathways
Monitor the effectiveness of interventions and report findings to the Practice Management and clinical teams
Support the practice in developing evidence-based approaches to improve patient outcomes
Identify opportunities to improve processes patient access service coordination and data quality
Contribute to PCN initiatives relating to prevention early intervention and population health

7 Health Inequalities and Population Health

Use practice data to identify groups experiencing poorer health outcomes or barriers to accessing services
Support targeted interventions for patients identified through population health management
Consider health inequalities when undertaking searches and developing patient cohorts
Identify patients who may benefit from prevention early intervention or proactive care
Work with the wider PCN and community partners to improve access to appropriate services
Support initiatives designed to reduce health inequalities and improve health outcomes
Monitor and report relevant outcomes where appropriate

8 Reporting and Communication

Translate complex data into clear and practical information for clinical and non-clinical audiences
Maintain accurate records of searches audits reports patient contacts and actions undertaken
Assist to provide authorised data requests within agreed timescales
Communicate effectively with clinicians practice managers administrators PCN staff research teams and external organisations
Ensure communication with patients is clear respectful and appropriate to their individual needs

9 Information Governance and Confidentiality

Maintain strict confidentiality when handling patient staff and organisational information
Comply with UK GDPR the Data Protection Act NHS information governance requirements and relevant practice and PCN policies
Only access patient-identifiable information where there is a legitimate and authorised reason
Follow approved procedures for data extraction storage analysis and transfer
Ensure information is anonymised or pseudonymised where appropriate
Maintain secure records of patient and practice information
Report actual or potential information governance breaches promptly
Complete all mandatory information governance data security and safeguarding training

Person Specification

Experience

Essential

Essential
Experience working with data databases spreadsheets or information systems
Experience using EMIS Web or another GP clinical system
Strong analytical and numerical skills
Excellent attention to detail and accuracy
Good knowledge of Microsoft Excel and data reporting
Ability to undertake searches and analyse primary care data
Ability to identify trends discrepancies and data quality issues
Excellent organisational and time-management skills
Ability to work independently and manage competing priorities
Excellent written and verbal communication skills
Ability to communicate effectively with clinical and nonclinical colleagues
Understanding of confidentiality and information governance
Ability to work effectively as part of a multidisciplinary team
Ability to communicate appropriately and sensitively with patients
Understanding of professional boundaries and the need to escalate clinical concerns

Desirable

Desirable
Experience working within NHS primary care
Experience with QOF monitoring and reporting
Knowledge of primary care clinical coding
Experience undertaking clinical searches and audits
Experience in care coordination or patient navigation
Experience supporting patients with long-term conditions or complex needs
Experience supporting research studies or research data collection
Knowledge of population health management
Experience with Power BI dashboards or other data visualisation tools
Knowledge of personalised care and support planning
Experience working with multidisciplinary teams
Understanding of health inequalities and social determinants of health
Research governance or Good Clinical Practice training

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Taunton Deane West Primary Care Network

Address

Wellington Medical Centre

Mantle Street

Wellington

Somerset

TA21 8BD

United Kingdom

Employer's website

https://tauntondeanewestpcn.gpweb.org.uk/our-primary-care-network

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