Primary Care Patient Coordinator Service

Tender description

NHS Hounslow Clinical Commissioning Group is offering a contract to the successful Bidder to provide coordinating staff to enhance and improve pro-active care, prevention and self care, to ensure a pro-active and planned care approach for patients registered with NHS Hounslow CCG GP Practices. The Service will work with the GP Practices that serve the Hounslow CCG registered population to provide the following: a. Work with each practice to plan and organise monthly Multidisciplinary Team meetings (MDTs) and with locality colleagues for quarterly Multidisciplinary Group meetings (MDGs). b. Liaise with patients, community health, social care and secondary care staff as required for MDT attendance and participation. c. Plan and review actions for MDT/MDG team members to support the care of the patient. d. Provide administration support for MDT/MDG meetings. e. Support the effective utilisation of the Whole Systems Integrated Care (WSIC) Dashboard within the practice. f. Support the effective utilisation of the Patient Activation Measure (PAM) in general practice. g. Support patient participation in the National Diabetes Prevention Programme (NDDP). h. Monitor and review Accident & Emergency/Urgent Care Centre activity in relation to complex patients/those with a care plan. These reports are provided by the CCG. i. Support the production and implementation of standard operating procedures and policies for processes such as call and recall and MDT meetings. j. Participate in quarterly action learning sets to discuss issues and share good practice. The Service will deliver a significant contribution to the achievement of locally defined outcomes: a) Better practice links with wider multidisciplinary locality teams b) Increased quality in care planning c) Increased use of voluntary and community services to support patients with LTCs d) Improved quality and standard of processes for proactive planned patient care across GP Practices e) Increased time for GPs to deliver patient facing care f) Patients feel more supported in the management of their Long Term Conditions (LTCs) g) Increased patient satisfaction h) Increased self-management by patients and carers i) Health and Social Care staff feel supported and motivated to deliver a new model of care NHS Hounslow CCG will be holding a bidder briefing event for this procurement at 09.30 on Wednesday, 19 October 2016 at Hounslow Civic Centre. Further details are included on the bidder briefing registration form which is attached to this advert.