Drake Medical Alliance Primary Care Network

Home Visiting Care Co-ordinator

The closing date is 04 June 2025

Job summary

Care Coordinators play an important role in the PCN by identifying and supporting patients manage their long-term health conditions. Care Coordinators work closely with GPs and practice teams to manage a caseload of patients, ensuring that appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.

The role of Care Coordinator with Home Visiting speciality is to provide support to the practice by being a supportive link between the practice and housebound patients, their family and carer(s) to provide the best outcome for the patient.

The role also involves collaborative working with our PCN pharmacy service which can include project work such as identifying patients, arranging and analysing metrics required for the pharmacy team to assess their medication needs.

Main duties of the job

Visiting housebound and care home residents on scheduled domiciliary visits for basic observations, blood tests, diabetic foot checks, collect of urine samples, QFit tests and wellbeing assessments.

Raising awareness with the appropriate professional in the event of concerns over patient health or wellbeing.

Support triage of information received via email, letter or via other platforms.

Use internal and external email and the internet to keep up to date and send and receive messages.

Supporting housebound patients, carers and care homes with referral to external services such as Social Prescribing, social care and befriending services.

Respond, using a helpful and problem-solving approach, to all queries and requests for assistance from practice staff, patients and care home staff.

About us

Drake PCN is a network of 5 surgeries, that are situated within the city of Plymouth. These are Lisson Grove Medical Centre, North Road West Medical centre, Knowle House surgery, Wycliffe surgery and Roborough surgery. We centrally employ our ARRS staff under a Limited Company which has access top the NHS Pension Scheme.

Date posted

21 May 2025

Pay scheme

Other

Salary

£12.87 an hour

Contract

Permanent

Working pattern

Full-time

Reference number

A2692-25-0008

Job locations

Drake Medical Alliance Network

Beacon Park Road

Plymouth

PL22PB

Job description

Job responsibilities

Use SystmOne to access patient records, add blood requests to ICE or equivalent pathology system with the appropriate clinician.

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.

Provide expertise to address both the public health and social care needs of patients, including lifestyle advice, service information, and help in tackling local health inequalities.

Ensure appropriate onward referral of urgent issues to an appropriate clinician.

Support the coordination and delivery of multidisciplinary teams.

Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients in having these conversations.

Maintain records of referrals and interventions to enable monitoring and evaluation of service.

Ensure appropriate SNOMED codes are used to record activity.

Have a positive, empathetic, and responsive conversation with the person, and their family and carer(s) about their needs.

Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance.

Work with the wider PCN, MDTs and the social prescribing service to look at how to support patients requiring personalised care and support.

Support patients as guided by the practice to manage health inequalities.

Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.

Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system.

Refer onwards to social prescribing link workers, occupational therapist and health and wellbeing coaches where required.

Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.

Actively participate in multidisciplinary team meetings in the PCN as and when appropriate.

Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.

Record what interventions are used to support people, and how people are developing on their health and care journey.

Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonable required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.

Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning.

Work in accordance with the practices and PCNs policies and procedures.

Contribute to the wider aims and objectives of the PCN to improve and support primary care.

Develop a culture that promotes equality and values diversity. The postholder must be aware of and committed to the Equality and Diversity policies of the appointing GP Federation and comply with all the requirements of these policies and actively promote Equality and Diversity issues relevant to the post.

Ensure the principles of openness, transparency and candour are observed and upheld in all working practices.

The post holder will have, or acquire through training provided by the organisation, the appropriate level of safeguarding and knowledge, skills and practice required for the post and be aware of and comply with the organisations safeguarding protection policies and procedures.

Ensure that any infection prevention and control issues are reported to the line manager/Infection Prevention and Control.