Job responsibilities
CARE COORDINATOR RESPONSIBILITIES
& DUTIES
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 a persons identified care and support needs and explore
options to meet these within a single personalised 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, using tools to
understand peoples level of knowledge, confidence in skills in managing
their own health.
Support
people to take up training and employment, and to access appropriate benefits
where eligible for example, through referral to social prescribing link
workers.
Assist
people to access self-management education courses, peer support or
interventions that support them to take more control of their health and
wellbeing.
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.
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.
EHCH RESPONSIBILITIES & DUTIES
You will work closely with the EHCH Advance Nurse Practitioner
to manage patient lists for the upcoming days/weeks, ensuring contingency
plans are in place and followed for unexpected leave.
Liaise
directly with care homes for non-clinical tasks such as booking and managing ward
round lists for clinical staff within the PCN SystmOne module.
Upon
request you will provide patient lists to the EHCH Advance Nurse Practitioner
in advance of planned visits for monthly GP ward rounds.
Managing
the EHCH inbox daily and dealing with requests in a timely manner. You will be required to follow a SOP for
referral requests and need to deal with non-clinical enquires the care homes
may have. You will also be required to
send confidential and encrypted emails at times.
You will be responsible for escalating clinical enquiries to the
EHCH Advance Nurse Practitioner in a timely manner.
Responsible for registering new care home patients as per the
SOP in Practice SystmOne modules.
If required, arrange the weekly MDT meeting on behalf of the
EHCH Advance Nurse Practitioner.
Produce
reports such as, but not limited to; care home bed capacity numbers, monthly
clinician appointment numbers and anything else requested by the EHCH Advance
Nurse Practitioner.
DIGITAL RESPONSIBILITIES & DUTIES
The Digital
Care Coordinator responsibilities & duties may include any or all of
those listed below. Duties may vary from time to time under the direction of
the PCN Leadership team, dependent on current and evolving PCN priorities and
workstreams.
Work closely with PCN colleagues to identify patients who
currently do not use digital channels for healthcare access, promoting
digital inclusion and encourage the wider use of the NHS App.
Use available data sources to help the multidisciplinary
teams understand the health and well-being profiles of our residents and to
identify specific groups of patients and arrange care for them. This will
include undertaking searches to identify individuals who meet particular
criteria, for example patients requiring blood pressure monitoring.
Assist the PCN to deliver improvements to the services we
provide our patients with relevant data and data analysis.
Support the PCN with coding activity appropriately and
develop reports to demonstrate PCN activity.
Assist the PCN member practices to engage with
hard-to-reach populations and to reduce health inequalities.
Take a lead in the deployment of new technologies and
education of patients.
Run regular proactive reports to identify patients who may
benefit from new services/new ways of delivering services and ensure
appropriate referrals are made.
Work with colleagues and partner organisations to promote
digital inclusion, for example, by demonstrating to and educating colleagues
about how to optimally use digital technologies and data/intelligence.
Support the PCN Administrator to develop social media
content for the PCN including website, Facebook - promoting ARRS roles,
services and health campaigns.
Providing data administration support to the PCN Leadership
team and member practices as required.
Any reasonable requests from the PCN Leadership team.
Act as an ambassador for use of digital healthcare
technology with both patients and colleagues.
Support PCN and member practices with handling and
analysing data and developing our digital maturity.
Support partner practices to maintain and monitor data
coding and quality on clinical systems, ensuring coding is compliant and
consistent.
Run system reports and extract data as required by the PCN
for activity reporting, using SystmOne clinical system,
PCN digital dashboard and other data sources.
Be a point of contact for digital enquiries and be an
active member of the NHS Dorset Digital CoP.
Under the direction
of the PCN Leadership team, support the implementation of digital projects
across the PCN and member practices.
