Job responsibilities
Accountable to: PCN Clinical Lead and PCN Business Manager
Salary: £25,147-£27,596 (Agenda for Change Band 4) dependent on experience
Job Summary
The Care Coordinator
will be part of the Primary Care Network (PCN) which is responsible for
managing the care of people registered with practices in the PCN. A key part of
the role of a care coordinator is in the Care Homes Multi-Disciplinary Team
(MDT), improving the continuity of care by acting as a point of contact for
residents, families and professionals who visit care homes. This will involve
coordinating the work of healthcare professionals and non-clinical staff
including volunteers and third sector agencies involved in the care of
registered patients.
They will support
the MDT with the weekly ward/home rounds through identification of people in
need of review, or collation of information on people requiring an MDT review
in addition to providing coordination and administrative support to the MDTs
within a single or multiple PCNs.
In this patient
facing role the post holder will also be responsible for a caseload of patients
identified through the MDT meetings. Support provided directly with patients
and their carers would include co-producing personalised plans, utilising
decision aids, providing information and training opportunities, making
appointments, coordination and navigation for people and their carers across
health and care services.
The post holder will
contribute to tackling inequalities in health and social care particularly
regarding individuals with long-term conditions. An ethos of promotion of
independence and partnership-working is integral to this post.
Primary Duties and Areas of Responsibility
Multi-Disciplinary Teams:
To take part in arranging the weekly PCN led MDT
meetings (including the weekly ward/home rounds) and the smooth running of
integrated care within the team setting. A key role of the Care Coordinator
will be to schedule the weekly MDT meetings, manage the meeting agenda items,
ensuring that all new referrals are identified, and information circulated to
team members in advance of the meeting.
Take minutes of MDT meetings and disseminate,
chase progress against actions identified in these meetings and ensure follow
up where necessary.
Direct patient facing work:
Manage a caseload of patients identified through
the MDT.
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 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.
Identify the training needs of care home staff and
escalate to the care home team or relevant professional appropriately.
Population Health Intelligence:
Utilise
population health intelligence, including Brave AI and related tools to
proactively identify and work with a cohort of patients to deliver personalised
care.
Receive and collate information from transfers
of care (including hospital admissions and discharges) plus out of hours calls
and present this information to the MDT as required.
Liaise with service providers and clinicians to
identify frequent flyers, and new service users utilising risk stratification
tools provided and present this information to the weekly MDT meetings.
Support the completion of new referrals by
checking criteria, and where criteria have been met, direct referral to the
MDT.
Signpost team members, service users and carers
to relevant services.
Communication and collaborative working relationships:
Liaise with other stakeholders as needed for the
collective benefit of patients including but not limited to Patients GP,
Nurses, other practice staff and other healthcare professionals including
pharmacists and pharmacy technicians from provider and commissioning
organisations.
Actively work toward developing and maintaining
effective working relationships both within and outside the PCN or group of
PCNs.
Work with service users, PCN practices and
partners e.g., Care Homes to ensure new referrals are logged and allocated.
Develop excellent working relationships with all
the partners, wider service networks including the voluntary sector, GP
practices, adult social care, hospitals, community pharmacists and other
members of the MDT.
Act as a point of contact for residents,
families, carers and professionals who visit the care home, such as MDT members
and in-reach specialists.
Recognise personal limitations and refer to more
appropriate colleague(s) when necessary.
Meet regularly with the clinical lead and review
case load and MDT function.
Provide background information about individuals
for the weekly MDT meetings.
Communicate effectively with service users and
their families/carers and provide coordination across health and care services
working closely with social prescribing link workers, health and well-being
coaches, and other primary care professionals.
Manage and prioritise workload on a daily basis
and deal with the competing demands of the MDT.
Patient Care:
Communicate effectively and sensitively and use
language appropriate to a patient and carer/relatives condition and level of
understanding.
Effectively use all methods of communication and
be aware of and manage barriers to communication.
Effectively recognise and manage challenging
behaviours, carers and or relatives.
Provide information to patients, their carers
and/or relatives on behalf of the team.
The PCN will ensure the Care Coordinator can
discuss patient related concerns and be supported to follow appropriate
safeguarding procedures (e.g., abuse and domestic violence) with a relevant GP.
Other responsibilities:
Act at all times in an anti-discriminatory
manner.
Plan and respond to workload according to
operational priorities.
Undertake any training required in order to
maintain competency including mandatory training.
Contribute to, and work within a safe working
environment.
The Care Coordinator must at all times carry out
duties and responsibilities with due regard to the PCN member practice equal
opportunity policies and procedures.
The Care Coordinator is expected to take
responsibility for self-development on a continuous basis, undertaking
on-the-job training as required.
The Care Coordinator must be aware of individual
responsibilities under the Health and Safety at Work Act, and identify and
report as necessary any untoward accident, incident or potentially hazardous
environment.
Respect for Patient Confidentiality
The post holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.
Job Description Agreement
This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.
