Job summary
Job summary
The post holder will receive, assist and direct patients in
accessing the appropriate service or healthcare professional in a courteous, efficient
and effective way whilst maintaining patient confidentiality. Facilitate
effective communication between patients, members of the primary health care
team, secondary care and other associated healthcare agencies.
To manage own workload in general practice responding to
patient and practice need and ensuring patient choice and ease of access to
services.
Undertake a variety of administrative duties to assist in
the smooth running of the practice including the provision of clerical support
to clinical staff and other members of the practice team.
Main duties of the job
Care Coordinators play a pivotal role within PCNs, proactively identifying and working with individuals, 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. This role is integral to the delivery of personalised care as outlined in the NHS Long Term Plan and the DES specification .
About us
i3 Primary Care Network Limited is a well-established network of primary care services based in the West of Birmingham, dedicated to delivering high-quality healthcare to a population of approximately 75,000 patients. Our organisation is committed to providing comprehensive and coordinated healthcare through a collaborative approach between our PCN-employed staff and the staff of our member practices.
We currently employ a team clinical and non-clinical professionals, working across our network to deliver personalised, patient-centered care. Our staff members benefit from being part of a supportive and dynamic team, working alongside experienced healthcare professionals within our practices.
As a registered employer with access to the NHS Pension Scheme, i3 Primary Care Network Limited offers secure and competitive benefits, supporting the health and wellbeing of our employees. Our commitment is to continuously enhance the quality of care we provide by expanding our workforce to meet the evolving healthcare needs of our population.
Job description
Job responsibilities
The post holder will be employed by i3 Primary Care Network Limited but will be primarily based at Soho Primary Care Centre and Hockley Medical Practice, with the flexibility to support other locations within the network as required.
1. Patient Identification and Engagement
- Proactively identify patients who would benefit from personalised care, including those with long-term conditions, multiple health needs, or who are frequent users of services.
- Serve as a first point of contact for patients, providing them with information, support, and navigation across primary, community, and social care services.
- Conduct patient assessments and gather relevant information to support care planning.
2. Personalised Care and Support Planning (Aligned with DES)
- Develop, review, and maintain personalised care and support plans (PCSPs) in collaboration with patients, carers, and the multidisciplinary team (MDT).
- Ensure that PCSPs are person-centred, addressing the patients goals, preferences, and health needs.
- Regularly review PCSPs to ensure they reflect the patient's changing needs and are shared appropriately with relevant professionals.
3. Coordination and Navigation of Care
- Act as a central point of contact for patients and carers, supporting them to navigate complex health and care systems.
- Work closely with general practice teams, social prescribing link workers, health and wellbeing coaches, and other PCN roles to ensure seamless patient care.
- Facilitate referrals and signpost patients to appropriate community, voluntary, and statutory services.
4. Multidisciplinary Team (MDT) Support
- Coordinate and participate in MDT meetings, providing patient updates, and supporting shared decision-making.
- Collaborate with GPs, practice nurses, pharmacists, mental health practitioners, and other professionals to deliver integrated care.
- Monitor patient progress against care plans and escalate concerns to the relevant clinician when necessary.
5. Health Coaching and Self-Management Support
- Support patients in developing self-management skills for their health conditions, promoting healthy lifestyle choices and preventive care.
- Provide information and support to patients on managing long-term conditions, including access to education, exercise, and support groups.
- Encourage patient activation and engagement in their own care, using motivational interviewing techniques.
6. Data Management and Reporting (DES Compliance)
- Maintain accurate and up-to-date patient records on the clinical system (e.g., EMIS, SystmOne), ensuring that all patient interactions and PCSPs are recorded.
- Provide data and reports as required for the PCN DES specification, including monitoring the impact of care coordination.
- Ensure compliance with data protection regulations and maintain patient confidentiality.
7. Administrative and Practice Support (General Practice Integration)
- Support general practice teams with administrative tasks as needed to ensure the smooth operation of patient services.
- Be prepared to provide reception support if necessary, including patient check-in, appointment booking, and answering general queries.
- Work flexibly to support general practice teams during peak periods or staff absences.
Job description
Job responsibilities
The post holder will be employed by i3 Primary Care Network Limited but will be primarily based at Soho Primary Care Centre and Hockley Medical Practice, with the flexibility to support other locations within the network as required.
1. Patient Identification and Engagement
- Proactively identify patients who would benefit from personalised care, including those with long-term conditions, multiple health needs, or who are frequent users of services.
- Serve as a first point of contact for patients, providing them with information, support, and navigation across primary, community, and social care services.
- Conduct patient assessments and gather relevant information to support care planning.
2. Personalised Care and Support Planning (Aligned with DES)
- Develop, review, and maintain personalised care and support plans (PCSPs) in collaboration with patients, carers, and the multidisciplinary team (MDT).
- Ensure that PCSPs are person-centred, addressing the patients goals, preferences, and health needs.
- Regularly review PCSPs to ensure they reflect the patient's changing needs and are shared appropriately with relevant professionals.
3. Coordination and Navigation of Care
- Act as a central point of contact for patients and carers, supporting them to navigate complex health and care systems.
- Work closely with general practice teams, social prescribing link workers, health and wellbeing coaches, and other PCN roles to ensure seamless patient care.
- Facilitate referrals and signpost patients to appropriate community, voluntary, and statutory services.
4. Multidisciplinary Team (MDT) Support
- Coordinate and participate in MDT meetings, providing patient updates, and supporting shared decision-making.
- Collaborate with GPs, practice nurses, pharmacists, mental health practitioners, and other professionals to deliver integrated care.
- Monitor patient progress against care plans and escalate concerns to the relevant clinician when necessary.
5. Health Coaching and Self-Management Support
- Support patients in developing self-management skills for their health conditions, promoting healthy lifestyle choices and preventive care.
- Provide information and support to patients on managing long-term conditions, including access to education, exercise, and support groups.
- Encourage patient activation and engagement in their own care, using motivational interviewing techniques.
6. Data Management and Reporting (DES Compliance)
- Maintain accurate and up-to-date patient records on the clinical system (e.g., EMIS, SystmOne), ensuring that all patient interactions and PCSPs are recorded.
- Provide data and reports as required for the PCN DES specification, including monitoring the impact of care coordination.
- Ensure compliance with data protection regulations and maintain patient confidentiality.
7. Administrative and Practice Support (General Practice Integration)
- Support general practice teams with administrative tasks as needed to ensure the smooth operation of patient services.
- Be prepared to provide reception support if necessary, including patient check-in, appointment booking, and answering general queries.
- Work flexibly to support general practice teams during peak periods or staff absences.
Person Specification
Qualifications
Essential
- Completion of Care Coordinator training as set out by the Personalised Care Institute (if this has not be completed prior you will be enrolled onto this course)
- Willingness to undertake further training as required.
Experience
Desirable
- Previous experience working in a primary care, community, or social care setting.
- Experience of working within a multidisciplinary team environment.
- Experience of working directly with patients, providing personalised care and support.
Skill and Attributes
Essential
- Excellent communication skills (written and verbal), with the ability to build trusting relationships with patients and professionals.
- Strong organisational skills with the ability to manage a caseload of patients and coordinate multiple services.
- Ability to work independently and as part of a team, demonstrating initiative and problem-solving skills.
- Compassionate, empathetic, and patient-focused, with a commitment to reducing health inequalities.
Desirable
- Proficiency in using clinical systems (e.g., EMIS) and Microsoft Office.
Person Specification
Qualifications
Essential
- Completion of Care Coordinator training as set out by the Personalised Care Institute (if this has not be completed prior you will be enrolled onto this course)
- Willingness to undertake further training as required.
Experience
Desirable
- Previous experience working in a primary care, community, or social care setting.
- Experience of working within a multidisciplinary team environment.
- Experience of working directly with patients, providing personalised care and support.
Skill and Attributes
Essential
- Excellent communication skills (written and verbal), with the ability to build trusting relationships with patients and professionals.
- Strong organisational skills with the ability to manage a caseload of patients and coordinate multiple services.
- Ability to work independently and as part of a team, demonstrating initiative and problem-solving skills.
- Compassionate, empathetic, and patient-focused, with a commitment to reducing health inequalities.
Desirable
- Proficiency in using clinical systems (e.g., EMIS) and Microsoft Office.
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
i3 Ladywood Primary Care Network
Address
247 Soho Road
Birmingham
B21 9RY