PCN - Care Co-ordinator

Job description

Job responsibilities

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

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

Be responsible for logging and making referrals;

Be responsible for arranging, attending and taking minutes at a MDT / work stream team meeting where appropriate;

Proactively prepare any actions prior to the MDT ensuring all relevant clinicians are present;

Follow up on all forward actions resulting from MDT discussions;

To work effectively as part of a team to provide cover within the Chesterfield and Dronfield PCN when required and to be flexible regarding working hours to meet the needs of the service;

Identify community pathways that might prevent hospital admission and identify any potential gaps in care;

Recognise opportunities to reduce inequalities and unwarranted variation in health care for the practice populations;

Participate in quality improvements and innovations, e.g. audits, significant events analysis and development of protocols and new services;

Record all patient interactions within the patient’s medical record and contribute to report generation, analysis and production;

To ensure all electronic records and tasks are updated and complete within the agreed time-scales;

To be customer focused (patient, carer, GP) when representing the work stream;

To work collaboratively with other teams and services to maintain an effective and efficient service;

To offer appropriate support and guidance to patients and their families / carers, utilising decision making aids in preparation for a shared decision-making conversation;

Holistically bring together all of a person’s 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;

To plan and organise work using own initiative, whilst being able to work as a valuable member of a team

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

To provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers and other primary care professionals

To support people to take up training and employment, and to access appropriate benefits where eligible

Work with the PCN to develop and support collective general practice projects;

Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested

Support the PCN team by inputting to the overall strategy development and programming of work streams by applying knowledge and understanding of programme and project management;

Engage with patient participation groups in line with PCN community engagement activities;

To provide excellent IT skills, to include Microsoft Office, Outlook and Excel

To undertake general administrative duties to support the role and any other reasonable duties as requested by a manager to ensure quality of service.

Person Specification

Experience

Essential

• Experience of working within health, community, social care or voluntary sector.
• Experience of Computer and Software packages. Including excellent use of Word and Excel.

Desirable

• Experience of using SystmOne or any other case management systems.
• Experience of working within primary care.
• Experience of working in a multi-disciplinary team.
• Experience of working with voluntary organisations including volunteers.
• Experience of producing individual care plans.
• Experience of managing a caseload.
• Experience of supporting people in a paid or unpaid capacity

Skills, Knowledge and Abilities

Essential

• Can organise and prioritise workload
• Knowledge of person-centred approaches.
• Understanding of local health and social care structures.
• Ability to work with patients on a 1:1 basis.
• Ability to listen, empathise with people and provide person-centred support in a non-judgemental way.
• Ability to work effectively as a member of a team.
• Ability to work effectively with colleagues, patients and external organisations.
• Ability to assess risk, anticipate difficulties and successfully address them
• Effective communication, both verbally and in writing.
• Willing to work flexibly within the team to cover annual leave or sickness, and to contribute to the extended hours' service if required.
• Ability to travel within the requirements of the role

Desirable

• Knowledge of the local voluntary sector and local services.
• Familiar with Safeguarding.

Qualifications

Essential

• NVQ Level 3, Advanced level or equivalent qualifications or working towards
• Demonstrable commitment to professional and personal development

Desirable

• Qualified and proven comprehensive knowledge of Microsoft packages including spreadsheets.

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

Arc Primary Care

Address

Arc Primary Care

Dunston Road

Chesterfield

Derbyshire

S41 8NG

Employer's website

http://www.arcprimarycare.co.uk/ (Opens in a new tab)