PCN Care Co-ordinator

Job responsibilities

We are 3 practices - Dunelm Medical Practice, Chastleton Medical Group and The Medical Group based across 9 surgery sites. We cover a geography that stretches from Framwellgate Moor through to Gilesgate and up to Tow Law. We are currently recruiting to two positions for our Primary Care Network who will work from the same base.

As patient care co-ordinator you will deal with patients and, if appropriate, their carer, before or after the patients consultation with a clinician or other healthcare professional. You will also act as support to practice staff by helping theme navigate patients to the most appropriate service for their needs.

Working closely with the patient and their clinician or other healthcare professional, you will co-ordinate patients healthcare and direct them to the appropriate service to ensure that they get the most suitable care.

The Care Coordinator role requires them to be able to work with and understand the roles of a variety of different people working in the practice and across the PCN including doctors, nurses, healthcare assistants, social prescribing link workers, physiotherapists, physician associates, paramedics, health and wellbeing coaches, podiatrists, occupational therapists and pharmacy technicians.

You may be given a caseload of identified patients and be required to ensure that their changing needs are addressed by considering local priorities, health inequalities and/or population health management risk stratification.

Care Coordinators will work closely with the PCN Social Prescribers and will help support the Better Health at Work award for the PCN and its member practices.

Your work will be directly linked to PCN performance overall. As the main purpose of your role (as set out in your job description) is to support the requirements of the Network Contract DES and in the achievement of associated performance indicators you may be required to work at any of sites of Durham West Primary Care Network (PCN).

Generic responsibilities

All staff at Durham West PCN have a duty to conform to the following:

Equality, Diversity and Inclusion

A good attitude and positive action towards ED&I creates an environment where all individuals are able to achieve their full potential. Creating such an environment is important for three reasons it improves operational effectiveness; it is morally the right thing to do, and it is required by law.

Patients and their families have the right to be treated fairly and be routinely involved in decisions about their treatment and care. They can expect to be treated with dignity and respect and will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Patients have a responsibility to treat other patients and our staff with dignity and respect.

Staff have the right to be treated fairly in recruitment and career progression. Staff can expect to work in an environment where diversity is valued, and equality of opportunity is promoted. Staff will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Staff have a responsibility to ensure that they treat our patients and their colleagues with dignity and respect.

Safety, Health, Environment and Fire (SHEF)

This PCN is committed to supporting and promoting opportunities for staff to maintain their health, well-being, and safety.

The post holder is to manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients and monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures, and guidelines.

All personnel have a duty to take reasonable care of health and safety at work for themselves, their team and others and to cooperate with employers to ensure compliance with health and safety requirements. All personnel are to comply with the Health and Safety at Work Act 1974, Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.

Confidentiality

The PCN and associated practices are committed to maintaining an outstanding confidential service. Patients entrust and permit us to collect and retain sensitive information relating to their health and other matters pertaining to their care. They do so in confidence and have a right to expect all staff will respect their privacy and always maintain confidentiality.

It is essential that, if the legal requirements are to be met and the trust of our patients is to be retained, all staff protect patient information and provide a confidential service.

Quality and Continuous Improvement (CI)

To preserve and improve the quality of PCN outputs, all personnel are required to think not only of what they do but how they achieve it. By continually re-examining our processes, we will be able to develop and improve the overall effectiveness of the way we work.

The responsibility for this rests with everyone working within the PCN and practices to look for opportunities to improve quality and share good practice and to discuss, highlight and work with the team to create opportunities to improve patient care.

Durham West PCN continually strives to improve work processes which deliver healthcare with improved results across all areas of our service provision. We promote a culture of continuous improvement where everyone counts, and staff are permitted to make suggestions and contributions to improve our service delivery and enhance patient care.

Staff should interpret national strategies and policies into local implementation strategies that are aligned to the values and culture of general practice.

All staff are to contribute to investigations and root cause analyses whilst participating in serious incident investigations and multidisciplinary case reviews.

Induction

In addition to the induction process at Durham West PCN, where you will be provided with a full induction programme, when attending any practice within the network you will also have a practice induction.

Whilst across the PCN we aim to standardise this process, inevitably there will be nuances particular to each practice. In any such instance, the practice management team will support you with this.

Learning and development

The effective use of training and development is fundamental in ensuring that all staff are equipped with the appropriate skills, knowledge, attitude, and competences to perform their role. All staff will be required to partake and complete mandatory training as directed by The PCN Manager. It is an expectation for this post holder to assess their own learning needs and undertake learning as appropriate.

The post holder will undertake mentorship for team members and disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments (e.g., courses and conferences).

The post holder will provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning.

Collaborative working

All staff are to recognise the significance of collaborative working and understand their own role and scope and identify how this may develop over time. Staff are to prioritise their own workload and ensure effective time-management strategies are embedded within the culture of the team.

Teamwork is essential in multidisciplinary environments and the post holder is to work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working. To work effectively with others to clearly define values, direction and policies impacting upon care delivery.

Effective communication is essential, and all staff must ensure they communicate in a manner which enables the sharing of information in an appropriate manner.

All staff should delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence.

Plans and outcomes by which to measure success should be agreed.

Managing information

All staff should use technology and appropriate software as an aid to management in the planning, implementation and monitoring of care and presenting and communicating information.

Data should be reviewed and processed using accurate SNOMED/read codes in order to ensure easy and accurate information retrieval for monitoring and audit processes.

Service delivery

Staff will be given detailed information during the induction process regarding policy and procedure.

The post holder must adhere to the information contained within the PCN and local practice policies and regional directives, ensuring protocols are adhered to at all times.

Security

The security of practice sites is the responsibility of all personnel. The post holder must ensure they remain vigilant at all times and report any suspicious activity immediately to their line manager.

Under no circumstances are staff to share the codes for the door locks with anyone and are to ensure that restricted areas remain effectively secured. Likewise, password controls are to be maintained and are not to be shared.

Professional conduct

All staff are required to dress appropriately for their role.

PCN staff members are to familiarise themselves and comply with local practice protocol.

Qualifications

Essential

• Primary responsibilities
• The following are the core responsibilities of the Carer Coordinator.
• There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels and the availability of a social prescribing link worker within the PCN:
• a. To work closely with practice and PCN healthcare roles, the PCC is to identify and work with a cohort of people to support their personalised care requirements, using any available decision support tools such as Care Navigation, templates and software.
• b. To collate all of a patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice.
• c. To help people to manage their needs by answering their queries and supporting them in making appointments.
• d. To support patients digitally where necessary and facilitate online access if required.
• e. To offer support with patients and their families to facilitate proxy online access.
• f. Liaise with patients and appropriate parties in response to Subject Access requests.
• g. To support people to access appropriate benefits where eligible as well as taking up employment and training.
• h. To assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools.
• i. To provide patients with high quality, easy to understand information to assist them in making choices about their care.
• j. To support patients in understanding their level of knowledge, skills and confidence (known as activation level) when participating in their health and well-being using, where appropriate, the PAM
• k. To liaise with Care Coordinators in other practices within the PCN and share best practice.
• l. To assist patients to access self-management education courses, peer support or interventions that support them in their health and well-being.
• m. Where appropriate, to assist patients to access personal health budgets.
• n. To provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW)
• o. To support in the delivery of enhanced services and other service requirements on behalf of the PCN
• p. To attend and participate in the delivery of multi-disciplinary teams (MDT) within PCNs.
• q. To undertake all mandatory training and induction programmes
• r. To contribute to and embrace the spectrum of clinical governance.
• s. To develop yourself and the role through participation in training and service redesign activities
• t. To attend a formal appraisal with their manager at least every 12 months and participation in regular supervision meetings. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed.
• u. To contribute to public health campaigns (e.g., flu clinics) through advice or direct care
• v. To maintain a clean, tidy, effective working area at all times
• Essential:
• Qualifications
• Educated to GCSE level or equivalent
• Skills
• Excellent communication skills (written and oral)
• Good IT skills
• Clear, polite telephone manner
• Effective time management (planning and organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving and analytical skills
• Ability to follow policy and procedure
• Personal qualities
• Polite and confident
• Flexible and cooperative
• Motivated
• Forward thinker
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure
• Other requirements
• Flexibility to work outside of core office hours
• Disclosure Barring Service (DBS) check

Desirable

• Desirable :
• Quaifications
• Passed training requirements as outlined by the Personalised Care Institute which will be live from April 2020
• Experience
• Experience of working in a health care setting
• Skills
• Good knowledge of MS Office and Outlook
• EMIS/Systmone/Vision user skills