PCN Care Coordinator Team Leader

Job description

Job responsibilities

The post will evolve as we develop our services but the postholder will be required to undertake the following duties:

Act as a point of contact between GP, patients and carers and other agencies

Develop and maintain a detailed knowledge of local community and voluntary sector services to enable supported signposting of people with an identified need.

Liaise with GPs and practice teams to identify patients who are elderly, frail or who have long-term health needs and support.

Liaise with primary, secondary and specialist care services as required.

Work with the multi-disciplinary team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.

Provide these cohorts of people signposting to identified services in order to maintain their independence and improve their health and wellbeing.

Visit patients in the community, home or care home settings to assess and discuss their care needs involving carers as appropriate.

Implement personal care plans for individual patients, ensuring preventative actions are detailed to support the appropriate use of services.

Communicate the care plan to the GP and any other professionals involved in the persons care and upload it to the relevant records.

Ensure that identified patients receive the right level of help at the right time and help them to experience a joined-up service by liaising with relevant service providers.

Work with patients, carers and healthcare team members to encourage the patient to adopt effective self-management and self-help seeking approaches to reduce unnecessary hospital admissions.

Liaise with other agencies to ensure timely and appropriate engagement as required.

Support patients to access community care assessments as well as carers assessments.

Where a personal healthcare budget is allocated provide advice as required regarding the key choices the patient will need to make.

Identify unpaid carers and direct them to access services as appropriate to provide them with support.

Identify when urgent action or a step up in care is required and promptly alert the relevant professionals involved, highlighting any safety concerns. Undertake training to be a carers champion and offer more in-depth support.

Follow up on communications from out of hospital and in-patient services regarding changes in the condition of patients to support the practice to respond proactively to potentially unmet needs.

Undertake visits or telephone contact to manage patients on the Practices caseload following any unplanned hospital admissions where appropriate.

To attend and participate in MDT meetings at the Practice plus any other meetings where there is a need to discuss Practice patients. Updates between meetings to be shared with key personnel on behalf of the Practice in accordance with data protection legislation.

Undertake visits or arrange appointments at the Practice for patients on the Practices caseload or otherwise as directed by the Duty Doctor following identification of urgent and non-urgent clinical needs to assess, diagnose, treat, prescribe and refer appropriately according to the patients health needs and acting within the Care Co-ordinators clinical skill set.

Maintain accurate and up-to-date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e., entering notes onto SystmOne using agreed read codes.

To run regular patient searches using SystmOne in order to have an up-to-date record of the progress of achievement of Key Performance Indicators.

Work with Wakefield CCG, Neighbourhood teams and other agencies to support and further develop this role.

Support the Manager in providing KPI reports for submission as requested.

To work closely with the practice and PCN healthcare roles, the CC is to identify and work with a cohort of people to support their personalised care requirements, (as the role develops)

To collate all of a patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice.

To assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools.

To liaise with other CCs in other practices within the PCN and share best practice.

To provide coordination and navigation of patients, and where appropriate their careers, across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW)

To support the delivery of enhanced services and other service requirements on behalf of the PCN

To undertake all mandatory training and induction programmes

To contribute to and embrace the spectrum of clinical governance.

To develop yourself and the role through participation in training and service redesign activities

To attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed.

To maintain a clean, tidy, effective working area at all times

Line Management Responsibilities

Ensuring that your team are working in an inspiring environment with a culture of respectful open communication.

Modelling NHS Values in your behaviour and conduct.

Setting clear goals and objectives with key performance indicators, motivating your team to achieve and celebrating their success.

Monitoring team and individual performance against specified metrics. Addressing issues related to performance in fair and timely manner.

Provide regular feedback and opportunities to actively listen to your team.

Encourage Innovation and Creativity.

Empower your team to develop their key skills.

Identifying training needs to support your team and provide coaching to maximise their potential.

Oversee the day-to-day operation of your team, knowing when to ask for support and guidance from the wider PCN and Leadership Teams.

Delegate tasks appropriately to team members to support the professional development and personal development goals. Set clear deadline sand monitor task progress.

Contribute to the Growth of the Primary Care Network by having a successful team, who deliver an effective, high-quality service.

Participate in the development of strategic plans, whole PCN objectives, ensuring alignment with Local and National Priorities.

Line Management Tasks

Conduct regular (6 weekly) one to ones/schedule performance reviews in line with PCN and Conexus Policies.

Develop Personal Development Plans, monitoring progress and making amendments in collaboration with your direct reports.

Suggest, plan, and organise team building and training activities.

Ensure compliance with Mandatory training for your team.

Pre-empt, and effectively manage conflicts within the team.

Approve and Manage Absence requests for your team, ensuring that the service is appropriately staffed, and task boxes are monitored.

Person Specification

Qualifications

Essential

• Educated to GCSE level or equivalent
• GCSE mathematics and English (C or above, or equivalent)

Desirable

• Leadership Qualification / proven work experience

Experience

Essential

• Evidence of a CPD portfolio
• Experience of working with vulnerable patients
• Evidence of working in a multidisciplinary team.
• Experience of working in a healthcare setting

Desirable

• 2 years experience working in general practice/primary care.
• 2 years experience as Line Manager / Team Leader
• Broad knowledge of general practice
• Experience of working in community/domicillary care/care homes.
• Experience of working with patients who have Long Term Conditions
• Experience of facilitating group work for service users.
• Experience of project planning
• An appreciation of the new NHS landscape including the relationships between individual practices, PCNs, and the commissioners

Aptitude

Essential

• Confidence and skilful negotiation skills
• Strong decision-making skills.
• Ability to delegate effectively.
• Ability to follow legal, ethical, professional, and organisational policies/procedures and codes of conduct.
• Ability to use own initiative, discretion, and sensitivity.
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
• Ability to use own initiative, discretion, and sensitivity.
• Flexible and cooperation
• Ability to identify risk and assess/manage risk when working with individuals.
• Sensitive and empathetic in distressing situations
• Able to provide leadership and to finish work tasks.
• Problem-solving & analytical skills
• Ability to maintain confidentiality.
• Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.

Other

Essential

• Flexibility to work outside of core office hours.
• Disclosure Barring Service (DBS) check
• Evidence of continuing professional development

Desirable

• Access to own transport and ability to travel across the locality on a regular basis

Knowledge and Skills

Essential

• Ability to communicate complex and sensitive information effectively with people at all levels by telephone, email, and face to face.
• Knowledge of IT systems, including the ability to use word processing skills, emails, and the internet to create simple plans and reports.
• Clear, polite telephone manner
• Effective time management (Planning and organising) of self and others.
• Demonstrate personal accountability, emotional resilience and work well under pressure.
• Ability to work autonomously and as part of a team

Desirable

• Good clinical system IT knowledge of EMIS/SystmOne/Vision
• SystmOne user
• Experience of working with people with low-level mental health needs and anxiety

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

Conexus Healthcare CIC

Address

Lupset Health Centre

George-a-green Court

Wakefield

West Yorkshire

WF2 8FE

Employer's website

https://conexus-healthcare.org/ (Opens in a new tab)