PCN Care Coordinator

Job description

Job responsibilities

A cohort of patients may be identified through population health management data and other means as requiring additional input; these may include those identified as being moderately to severely frail, at risk of hospital admission, those who have just been discharged with an urgent care package, those with a cancer diagnosis and patients discussed at wellbeing, multidisciplinary team or palliative care meetings.

Our PCN Care Coordinator has the following key responsibilities in supporting the delivery of health services to these patients:

1. Liaising with patients and, if appropriate, their families and carers, before or after the patients consultation with a clinician or other healthcare professional to support the delivery of personalised care so patients and their families or carers feel more able to manage their care.

1. Proactively contacting patients who have been discharged home from hospital with an urgent care package to ensure there is no breakdown in care;

1. Provide coordination and navigation for people and their carers across health and care services, helping patients with complex needs to manage these needs through answering queries, making and managing appointments, and ensuring that people have received good quality written or verbal information to help them make choices about their care. This includes supporting patients to utilise decision aids in preparation for a shared decision-making conversation, understanding their level of knowledge, confidence in skills in managing their own health and navigate the healthcare system.

1. Supporting the coordination and delivery of Multidisciplinary Team working within the PCN by working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals. This is so the patient knows how to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activity level.

1. Coordinating any summary care and support plans that are necessary with input from health and social care professionals across the multidisciplinary teams. This is with the aim of supporting the proactive planning of care, finding practical solutions to support a better quality of every daily living for the patient, improve the knowledge and highlighting support for those caring for the patient, and reduce exacerbations of illness and/or unnecessary admissions to hospital.

1. Arranging, where necessary, follow up appointments and/or appointments for tests so referrals can be progressed;

1. Proactively chasing up screening appointments that were not attended (often referred to as DNAs);

1. Proactively chasing up urgent referrals for suspected cancer;

1. Filing and retrieving paperwork;

1. Completing basic (non-opinion) forms and core elements of some forms for the GP to approve and sign such as insurance forms, mortgage, access to training and employment, benefits agency forms etc;

1. Supporting the proactive management of defined patient cohorts through searching the clinical system and production of data to facilitate clinical audit;

1. Promote digital inclusion and identity patients and groups of patients who are digitally excluded.

There is a degree of overlap with some of the responsibilities of the PCN General Practice Assistant (GPA) role, the following tasks form part, but are not the main responsibilities of the role:

1. Scanning hard copy letters and clinical correspondence and attaching to patients notes, ensuring information is not duplicated;

1. Processing all patient-related correspondence received in paper or electronic form according to the PCN workflow protocol, utilising any workflow software as available;

1. Adding the relevant clinical codes and investigations from the clinical correspondence into patients notes so the record is complete and the patient, where appropriate, is added automatically to disease registers and recall for review;

1. Ensuring any straightforward non-clinical administrative procedures are completed prior to the clinician reading the correspondence with actions to date clearly outlined;

1. Signposting correspondence to other members of the team for action where necessary e.g. reception to make an appointment, the prescribing team for a review of medication following discharge;

1. Ensuring the appropriate information is available for patients to review if they have electronic access to their clinical record;

Additional depending on experience and training

1. Raising awareness of clinical and non-clinical staff on the role of the care coordinator and the benefits of personalised care;

1. Participating in the management of patient complaints when requested to do so and participate in the identification of any necessary learning brought about through incidents and learning events;

1. Acting as a chaperone as required.

There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels.

Person Specification

Qualifications

Essential

• The equivalent of four GCSE Grade 4 and above including attainment of the equivalent of level 2 functional skills in English and Maths.

Desirable

• One A level or equivalent.

Personal qualities

Essential

• Courteous, respectful and helpful at all times
• Flexible and cooperative and able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
• Confident and can work on own initiative whilst being aware of own boundaries of competence and what to do when boundaries are reahed
• Motivated, forward-thinking problem solver.
• Ability to work to meet deadlines.
• Understand the needs of the patient and the meaning of personalised care.
• Effectively utilise resources.
• Punctual and committed to supporting the practice and PCN team efforts.

Experience

Essential

• Experience of working in a healthcare setting.
• Experience of working with the general public.

Desirable

• Experience of working in primary care.

Wider responsibilities

Essential

• Commitment to ongoing professional development.
• Satisfactory Enhanced Disclosure Barring Service (DBS) check.
• Access to transport in order to work at the PCN office and travel if necessary to another PCN site.

Desirable

• Understanding and knowledge of healthcare provision in GP surgeries, the Qualities and Outcomes Framework and enhanced services.
• Understand the roles of a variety of different people working in the practice and across the PCN.

Skills

Essential

• Effective communication skills (written and oral) with a clear, polite telephone manner.
• Ability to work independently.
• Ability to process information accurately and effectively, interpreting data as required.
• Strong IT skills and competent in the use of Microsoft Office applications and the internet.
• Effective time management (planning, prioritising and organising)
• Good interpersonal skills with the ability to listen, empathise with people and provide person-centred support in a non-judgemental way
• Commitment to reducing health inequalities and proactive working to reach people from all communities.
• Ability to work as a team member and autonomously.
• Knowledge of and ability to work to policies and procedures including information governance, management of clinical correspondence, on-line access, mental capacity and safeguarding.

Desirable

• Good knowledge of GP clinical systems EMIS or SystmOne or Vision

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

TASC PCN

Address

Seaton & Colyton Medical Practice

148 Harepath Road

Seaton

Devon

EX12 2DU

Employer's website

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