Job responsibilities
Post: PCN Care Coordinator
Salary: £25 28,000 (inclusive of London Weighting)
Hours: 37.5 Hours
Accountable To: Senior PCN Development Manager
Location: Across the Healthsense PCN practices
Purpose of the role
Care
coordinators play an important role within a PCN to proactively identify and
work with people, including the frail/elderly and those with long-term
conditions, to provide coordination and navigation of care and support across
health and care services.
They work closely
with GPs and practice teams to manage a caseload of patients, acting as a
central point of contact to ensure 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.
This is
achieved by bringing together all the information about a persons identified
care and support needs and exploring options to meet these within a single
personalised care and support plan, based on what matters to the person.
Care
coordinators review patients needs and help them access the services and
support they require to understand and manage their own health and wellbeing,
referring to social prescribing link workers, health and wellbeing coaches, and
other professionals where appropriate.
Care
coordinators could potentially provide time, capacity and expertise to support
people in preparing for or following-up clinical conversations they have with
primary care professionals to enable them to be actively involved in managing their care and supported to make choices
that are right for them. Their aim is to help people improve their quality of life.
The
successful candidate will be based in a local cluster of General Practices as
part of Healthsense Primary Care Network (PCN). They will be caring, dedicated,
reliable and person-focused and enjoy working with a wide range of people. They
will have good written and verbal communication skills and strong
organisational and time management skills. They will be highly motivated and
proactive with a flexible attitude, keen to work and learn as part of a team
and committed to providing people, their families and carers with high quality
support.
This role is
intended to become an integral part of the PCNs multidisciplinary team,
working alongside social prescribing link workers and health and wellbeing
coaches to provide an all-encompassing approach to personalised care and
promoting and embedding the personalised care approach across the PCN.
There may be a need to work remotely depending on the requirements of
the role. Please note that the role of a care coordinator is not a clinical
role.
Key responsibilities
The
postholder will support the PCN management with conducting searches on data
cohorts and helping to meet Impact and Investment Fund (IIF) indicators and
Enhanced Service workstream targets.
Work with people, their
families and carers to improve their understanding of the patients condition
and support them to develop and review personalised care and support plans to
manage their needs and achieve better healthcare outcomes.
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.
Assist people to access
self-management education courses, peer support, health coaching and other
interventions that support them in their health and wellbeing, and increase
their levels of knowledge, skills and confidence in managing their health.
Support people to take up
training and employment, and to access appropriate benefits where eligible; for
example, through referral to social prescribing link workers.
Provide coordination and
navigation for people and their carers across health and care services, working
closely with social prescribing link workers, health and wellbeing coaches, and
other primary care professionals; helping to ensure patients receive a
joined-up service and the most appropriate support.
Work collaboratively with GPs
and other primary care professionals within the PCN to proactively identify and
manage a caseload, which may include patients with long-term health conditions,
and where appropriate, refer back to
other health professionals within the PCN.
Support the coordination and
delivery of multidisciplinary teams with the
PCN.
Raise awareness of how to
identify patients who may benefit from shared decision making and support PCN
staff and patients to be more prepared to
have shared decision-making conversations.
Explore and assist people to
access a personal health budget where appropriate.
Work with people, their
families, carers and healthcare team members to encourage effective
help-seeking behaviours;
Identify unpaid carers and help
them access services to support them;
Conduct follow-ups on
communications from out of hospital and in-patient services;
Support practices to keep care
records up-to-date by identifying and updating missing or out-of-date
information about the persons circumstances.
Key
Tasks
1.
Enable access to personalised care and support
a. Take referrals for individuals or proactively identify people who
could benefit from support through care coordination;
b. Have a positive, empathetic and responsive conversation with the
person and their family and carer(s) about their needs;
c. Work towards increasing patients understanding of how to manage and
develop health and wellbeing through offering advice and guidance;
d.
Develop an in-depth knowledge
of the local health and care infrastructure and know how and when to enable
people to access support and services that are right for them;
e. Use tools to measure peoples levels of knowledge, skills and
confidence in managing their health and to tailor support to them accordingly.
f.
Work with the wider PCN, MDTs,
and the social prescribing service to
look at how carers can support people - this could include the initial
identification of carers onto the carer register
g. Support people to develop and implement personalised care and
support plans;
h.
Review and update personalised
care and support plans at regular intervals;
i.
Ensure personalised care and
support plans are communicated to the GP and any other professionals involved
in the persons care and uploaded to the relevant online care records, with
activity recorded using the relevant SNOMED codes;
2.
Coordinate
and integrate care
a. Making and managing appointments for patients, related to primary,
secondary, community, local authority, statutory, and voluntary organisations
b.
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;
c. Refer onwards to social prescribing link workers and health and
wellbeing coaches where required;
d. 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;
e. Actively participate in multidisciplinary team meetings
f.
Identify when action or
additional support is needed, alerting a named clinical contact in addition to
relevant professionals, and highlighting any safety concerns.
g. Record what interventions are used to support people, and how people
are developing on their health and care journey;
h. Keep accurate and up-to-date records of contacts, appropriately
using GP and other records systems relevant to the role, adhering to
information governance and data protection legislation;
i.
Work sensitively with people,
their families and carers to capture key information, while tracking of the
impact of care coordination on their health and wellbeing;
j.
Encourage users to provide feedback and to share their stories about the
impact of care coordination on their lives;
k. Record and collate information according to agreed protocols and contribute to evaluation reports
required for the monitoring and quality improvement of the service.
3.
Professional development
a.
Work with a named clinical
point of contact for advice and support.
b. Undertake continual personal and professional development, taking an
active part in reviewing and developing the role and responsibilities, and provide
evidence of learning activity as required;
c.
Adhere to organisational
policies and procedures, including confidentiality, safeguarding, lone working,
information governance, equality, diversity and inclusion training and health
and safety.
4.
Miscellaneous
a. Establish strong working relationships with GPs and practice teams
and work collaboratively with other care coordinators, social prescribing link
workers and health and wellbeing coaches, supporting each other, respecting
each others views and meeting regularly as a
team;
b. Act as a champion for personalised care and shared decision making
within the PCN;
c. Demonstrate a flexible attitude and be prepared to carry out other
duties as may be reasonably 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;
d. Identify opportunities & gaps in the service and provide feedback
to continually improve the service and contribute to business planning;
e.
Work in accordance with the
practices/PCNs policies and procedures;
f.
Contribute to the wider aims
and objectives of the PCN to improve and support primary care.
