PCN Care Co-ordinator

Job description

Job responsibilities

Job Summary:

Care Coordinators play an important role in working with people who have been identified as complex or vulnerable, including the frail/elderly and those with long-term conditions, to provide coordination and navigation across health and care services. They work closely with GPs and Practice Teams, acting as a central point of contact to ensure appropriate support is made available to the patient and their carers. This role requires strong organisational and communication skills. Has some clinical patient assessment aspects (phlebotomy, bp, etc training can be provided)

Care Coordinators bring together all the information about a patients care and support needs and helps to create a personalised care and support plan based on what matters to the patient. They help patients to access services, referring to Social Prescribing Link Workers, Health and Wellbeing Coaches and other roles in our Wellbeing Hub.

A key responsibility of the role is to provide strong administration support to the weekly Care Home Multi Disciplinary Team (MDT) meetings: setting up meetings, minuting and following up on actions and acting as the liaison between MDT members and Care Home staff, community team, Enhanced Health Checks

Job responsibilities:

Direct patient facing work

Work collaboratively with staff across the PCN to proactively identify and support patients; working with those patients, their families and carers, to provide coordination and navigation across health and care services.

Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), based on what matters to the person. This will be done in liaison with clincial staff and Social Prescriber Link Workers who can advise on community services.

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.

Receive and collate information from transfers of care (including hospital admissions and discharges), out of hours calls, DNARs etc and follow up with the patient to identify their needs.

Collaborative working relationships

Collaboratively work with other Care Coordintors, managing the workload as a team and covering duties for other Care Coordinator absences.

Work as a cohesive team with the other staff in the Wellbeng Hub, receiving referrals and identifying which Wellbeing Hub roles could best support the patient. This might include for example, working with the Social Prescribing Link Workers to support people in to training and/or work, support people to understand their level of knowledge, skills and confidence (their Activation level), support people to access personal health budgets and support PCN staff and patients to be more prepared to have shared decision-making conversations.

Actively work toward developing and maintaining effective working relationships both within and outside the PCN, communicating effectively with service users and their families/carers, building networks with GP practices, adult social care, hospitals, community pharmacists etc.

Supporting Care Delivery

Follow through actions identified by Clinical Staff or Care Home MDTs, including arranging tests, referrals, signposting etc.

Follow up with service users and others involved to ensure all services and care arrangements are in place.

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

Keep care records up-to-date as activities arise, uploading care plans to EMIS, identifying and updating missing or out-of-date information about a persons circumstances etc.

Contribute to risk and impact assessments, monitoring and evaluations of the Care Coordinator role and the Wellbeing Hub.

Confidentiality

• In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately
• In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential
• Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data

Information Technology

Work closely with the PCN manager and the team to ensure that PCN documentation and other important documentation is maintained on the Document Management System - Teams

Work closely with Practice Managers to manage Data collection, record appropriate coding, analyse reports etc to enable informed decision making and continuous quality improvement.

Manage reporting requirements for the Care Home MDT.

Please see attachment for full Job Description.

Person Specification

Skills and Attributes

Essential

• Proven record of excellent written and verbal communication skills and interpersonal skills
• Evidence of excellent knowledge of Microsoft Office
• Able to deal with service users sensitively
• Able to work as part of a team
• Able to prioritise and manage own workload
• Excellent motivational and influencing skills
• Excellent negotiating skills
• Car user (to travel between more than one GP practice)
• Excellent interpersonal skills
• Strong analytical and judgement skills
• Ability to analyse and interpret information and present results in a clear and concise manner
• Excellent organisational and administration skills
• Experience providing advice/signposting to customers or patients

Desirable

• Able to use NHS Choices website effectively

Experience

Essential

• Experience of working in an administrative capacity, supporting customers or patients and/or previous experience in the NHS or social care or relevant field
• Experience in use of databases
• Experience of administrative duties
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality
• Working in a busy and demanding environment whilst delivering in a timely manner

Desirable

• Working in a multi-disciplinary setting where influence and negotiation is required
• Knowledge/familiarity with medical terminology
• Understanding of current issues facing the NHS
• Understanding of health and social care processes

Qualifications

Essential

• 5 GCSEs grade C/4 or above/Diploma/ HNC level (or relevant experience)

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

Glenroyd Medical Practice

Address

Moor Park Health and Leisure Centre

Bristol Avenue

Bispham, Blackpool

FY2 0JG

Employer's website

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