PCN Care Co-ordinator

Job description

Job responsibilities

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

2. To work with the AWT to identify and manage a caseload of patients and where appropriate, refer people back to other health professionals within the PCN.

3. Develop excellent working relationships with the key stakeholders as listed above.

4. Direct liaison with multi agencies to coordinate care for patients.

5. Fulfil an intermediary role between individuals, receptionists, administrators, clinicians, social workers, therapist and mental health teams.

6. Keep SystmOne/EMIS up to date with relevant records for colleagues involved in care to be able to access.

7. Keep an update to date portfolio of reflections and good case management stories. You will be allocated a Lead Clinician for supervision.

8. Work with colleagues to ensure a point of contact is available to case-managed or potentially case-managed individuals at all times during working hours.

9. Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public.

10. Communicate with other members of the integrated care system including Local Navigation Hub, if individuals need to access other services.

11. Refer and identify complex cases following process with the Leads GPs.

12. Recognise opportunities to reduce inequalities and unwarranted variation in health care for the practice population.

13. Manage and prioritise workload on a daily basis and deal with the competing demands of the service.

14. Act as an advocate with patients, families, friends and carers to support the assessment and identification of specific needs to maintain independence in the community. To offer appropriate support and guidance to patients and their families / carers, utilising decision-making aids in preparation for a shared decision-making conversation.

15. 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.

16. Coordinate and manage a designated caseload and work with the clinicians to recommend the best course of intervention while participating in regular caseload management supervision to ensure caseload remains fluid, comprising of active patients of a manageable size.

17. Where there are safeguarding concerns, the Care Coordinator should follow the safeguarding policy and raises issues accordingly.

18. Signpost team members, service users and carers to relevant service, referring as appropriate. 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.

19. Contribute to assessments to identify a specific need, to maintain independence in the place they call home (own home, residential home etc).

20. Coordinate, attend and manage the administrative functions of MDT and/or CST meetings which will involve identifying external services/people to attend. Take minutes of AHVT meetings and disseminate; chase progress prior and following against actions identified in these meetings.

21. 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.

22. Identify and build networks and/or pathways that might prevent hospital admission and/or raise awareness for particular cohorts within the community e.g. Learning Disabilities, complex patients.

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

24. Record all patient interactions within the patients medical record and contribute to report generation, analysis and production.

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

26. 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.

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

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

29. 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.

30. Engage with patient participation groups in line with PCN community engagement activities.

31. 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

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.
• Working with case loads

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.
• Previous experience of care co-ordination
• Successfully passed the 2 day personalised accreditation care coordination course

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

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

https://www.chesterfieldanddronfieldpcn.nhs.uk/ (Opens in a new tab)