Lodge Road Surgery

PCN Care Coordinator

This job is now closed

Job summary

Care coordinators play an important role within a practice and the 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.

Care coordinators help patients negotiate their way through the NHS and so can help them organise secondary care follow up or appointments within the wider NHS. They will also coordinate community care of complex patients after their admission to hospital. Their aim is to help people access the healthcare they need across all settings.

Main duties of the job

Care coordinators will attend multidisciplinary team meetings within the practice and the wider PCN and will have a central role in organising those meetings with the clinicians and ensure appropriate follow up for patients occur.

The successful candidate will be based at Lodge Road Surgery, but will be expected to work within PCN practices when required.

They will be caring, dedicated, reliable and person-focussed 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.

Please note that the role of a care coordinator is not a clinical role

About us

Lodge Road Surgery is the Lead Practice for Central Health Partnership PCN. Our PCN has a total list size of around 55,000 patients across 7 practices in the West Midlands.

Date posted

16 February 2024

Pay scheme

Other

Salary

£13 to £13.80 an hour

Contract

Permanent

Working pattern

Full-time

Reference number

A5343-24-0001

Job locations

Lodge Road Surgery

Lodge Road

Smethwick

West Midlands

B67 7LU

Job description

Job responsibilities

To provide direct support to the Social Prescribing and Clinical Pharmacy Role and provide a coordinated approach across the PCN member practices. Complete evaluation, efficiency and reporting of ARRS roles where required to meet NHS/PCN guidelines.

To provide support to the Social Prescriber team in building out and supporting voluntary groups/organisations, develop content and maintaining the accuracy of the Directory of Services.

Set up and managing a group for patients where the demand is not met by CVS or local groups (e.g. a walking group or coffee morning for the lonely).

Work with Clinical Pharmacist to facilitate group consultations i.e care home patient reviews and support the delivery of the Clinical Pharmacy required outcomes.

Produce monthly news letters for the ARRs roles

Organise meeting, produce agendas and minute meeting for the Social Prescribers, Clinical Pharmacists and other ARRs roles and the lead practitioners.

Working with Individual Practice Clinicians and Practice Managers to be responsible for the management of the coordination for the assessment of Learning Disability Patients and other joint projects as needed.

tilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care;

support people to utilise decision aids in preparation for a shared decision-making conversation and to take up training and employment help them in accessing appropriate benefits where eligible

Work with people to bring together a single personalised care and support plan (PCSP), in line with PCSP best practice.

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. Offer support to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure;

assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level. Explore and assist people to access personal health budgets where appropriate;

work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN;

To co-ordinate recall lists for patients who are being monitored for chronic health conditions

Identify unpaid carers and help them access services to support them.

Conduct follow-ups on communications from out of hospital and in-patient services.

To follow up patients who have been discharge from hospital to ensure all discharge actions have been carried out and to identify any additional needs to reduce the risk of readmission.

Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances.