PCN Care Coordinator

Job description

Job responsibilities

Job description

Overview

The Care Coordinator will work with the GPs and other clinicians within the Primary Care Network to identify and manage a caseload of patients. This will require coordination of care between our own clinicians and those within our external Partners.

There is a need to raise awareness internally and with the patients around shared decision making, making best use of shared decision making tools. We also need to raise awareness of how to identify patients who would benefit from shared decision making.

There are numerous work streams under our contract and the care coordinator will work closely with the PCN Manager and Clinical Director to establish these so they work effectively and have robust governance and reporting processes in place around each stream of activity.

Main duties of the role

1. Work with GPs and other clinicians, supported by data, to identify cohorts of patients who will benefit from personalised care.

2. Work closely with our well established Social Prescribing Link Workers in the community to establish what works best for each patient.

3. Support patients to use decision making aids to prepare them for a shared care conversation

4. Bring all of a patients identified care and support needs into a personalised care plan based on what matters to the patient.

5. Support patients to engage in training and employment, accessing education and other interventions that will improve their wellbeing.

6. Where appropriate help patients to access their personal health budgets

7. Support the delivery of MDTs within the PCN

8. On a wider basis become a contact point within the PCN for patients who are:

• seriously mentally ill

• Complex or frail

• Frequent attenders for GP appointments

• Recently discharged from hospital

• Requiring active signposting to support services

• New patients to our list with specific needs

Management

1. Leadership of service evaluation to enable and promote quality improvement

2. Manage our resource effectively to manage treatment in line with local guidance and make recommendations for change where appropriate

3. Design and implement organisational policies to ensure robust delivery of service aims

Collaboration

1. Work effectively across the Bridge View Medical team

2. Establish good working relationships with our external PCN Partners so that there is a seamless transition between providers for the patient.

Education and training

1. Complete the required training for the role provided by the Institute of Personal Care

2. Engage with all statutory and mandatory training required by Bridge View Medical

3. Participate in training of other members of staff

4. Undertakes any additional training identified during the course of the job

5. Keep up to date with current guidelines applicable to the role

Quality

1. Participate in governance and audit activity to contribute to the improvement in quality of health outcomes

2. Use the available significant event reporting process and alert appropriate team members to areas of risk

3. Meet all deadlines for audits and reporting to ensure the PCN meets its contractual requirements

4. Effectively manage own time and workload

Person Specification

Qualifications

Essential

• NVQ Level 3 or A levels

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

Bridge View Medical

Address

67 Coronation Road

Bristol

BS3 1AS

Employer's website

https://bridgeviewmedical.nhs.uk/ (Opens in a new tab)