PCN Care Coordinator - Healthcare Assistant

Job description

Job responsibilities

Core Responsibilities

Undertake long term condition (LTC) and dementia reviews for care/nursing home residents.

Ensuring care plans are in place for care/nursing home residents and kept up to date on the patients records.

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care;

Support patients to utilise decision aids in preparation for a shared decision-making conversation;

Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalized care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person;

Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care;

Support people to take up training and employment, and to access appropriate benefits where eligible;

Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure;

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level;

Explore and assist people to access personal health budgets where appropriate;

Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals;

Support the coordination and delivery of MDTs within the PCN.

Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN;

Raise awareness within the PCN of shared-decision making and decision support tools;

Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.

Safeguard patients by ensuring organisations and groups to whom its Care Coordinator directs patients have basic safeguarding processes in place for vulnerable individuals and provide opportunities for the patient to develop friendships and a sense of belonging, as well as to build knowledge, skills and confidence.

Strategy and Leadership

Understands, and contributes to, the PCN strategic plan.

Able to improve quality within limitations of service.

Understands the implications of national priorities for the team and/or service

Demonstrates understanding of, and conforms to, relevant standards of practice

Demonstrates ability to identify and resolve risk management issues according to policy/protocol.

Relationships

Work closely and in partnership with the Social Prescribing Link Worker(s) or social prescribing service provider and Health and Wellbeing Coach(es),

Recognises the roles of other colleagues within the organisation and their role in patient care

Demonstrates use of appropriate communication to gain the co-operation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals, other NHS/private organisations e.g. CCGs)

Demonstrates ability to work as a member of a team

Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary

Liaises with other GP Practices and staff as needed for the collective benefit of patients

Person Specification

Qualifications

Essential

• GCSE grade A to C in English and Maths
• NVQ3 Health & Social Care
• Training for giving vaccines
• Is enrolled in, undertaking or qualified from appropriate training as set out by the Personalised Care Institute

Experience

Essential

• Experience working in a similar role for at least 5 years

Desirable

• Experience of working in primary care
• Experience of working in a GP practice

Knowledge and Skills

Essential

• Excellent interpersonal and communication skills
• Good IT skills
• Empathy and good listening skills
• Able to work autonomously and as part of a team

Training and Development

Essential

• Ability to undertake further training

Miscellaneous

Essential

• Full, clean driving licence

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

Ruby Country Medical Group

Address

Dobles Lane

Holsworthy

Devon

EX22 6GH

Employer's website

https://www.rubycountrymedicalgroup.co.uk/ (Opens in a new tab)