PCN Care Coordinator

Job description

Job responsibilities

The post holder will join an expanding team of Care Coordinators within our innovative Living Well Team and will be required to organise and coordinate the multi-faceted care needs of patients across our PCN.

The role requires the post holder to be able to work with, and understand the roles of, a variety of different people working in the practice and across the PCN in primary care, secondary care and community settings, eg doctors, nurses, healthcare assistants, social prescribing link workers, occupational therapists, physiotherapists, therapists and clinical pharmacists.

Working closely with the patient and their clinician or other healthcare professionals, the care coordinator will establish and provide:

Care Navigation

Medicines/Pharmacy support/coordination

Digital education & enabling

Tracking patients through system

In reach & assisting with discharge eg wards, SDEC, A&E

Contact & support after 111/EMAS/A&E/ Admission

Care plan reviews

Act as link with wider team LWT, CPT, MHT, NT, Practices, Community Pharmacy

Enhanced Health in Care Homes (EHCH) Support

The post holder will be enrolled in (or be prepared to enrol in and complete the next available course), undertaking or qualified from appropriate training as set out by the Personalised Care Institute.

The post holder will receive appropriate clinical supervision and a named individual in the PCN to provide general advice and support on a day-to-day basis.

The role will require the ability to work flexibly to meet the needs of the organisation and this may include working outside of core General Practice hours from time to time within our Enhanced Access service.

The role will be an integral part of the Living Well Team and support general practice by working within and across member practices. The post holder will be based at South Lincoln Healthcare Collaborative work space at Waddington but will also be required to work from home and within member practices.

The post holder will need to hold a full driving licence and be prepared to travel between locations to support the remit of the role.

Work as part of a multi-disciplinary team within the PCN, working closely with practice and PCN healthcare roles, the care coordinator is to identify and work with the identified cohort of patients to support their personalised care requirements, using any available decision support tools such as Patient Activation Measure (PAM), templates and software.

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.

Help people to manage their needs by answering their queries and supporting them in making appointments.

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.

Provide patients with high quality, easy to understand information to assist them in making choices about their care.

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.

Assist patients to access self-management education courses, peer support or interventions that support them in their health and well-being.

Where appropriate, to assist patients to access personal health budgets.

Where appropriate, to support people to access appropriate benefits where eligible as well as taking up employment and training.

Provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working closely with social prescribing link workers, occupational therapists and other primary care professionals.

Attend and participate in the delivery of multi-disciplinary teams (MDT) within PCNs.

Share best practice across the PCN.

Be responsible for the day-to-day planning of personal workloads

Follow departmental policies procedures and guidelines

Develop yourself and the role through participation in training and service redesign activities

Contribute to a patient safety culture through reporting and investigation of incidents and undertaking proactive measures to improve patient safety

Actively signpost patients to the correct healthcare professional

Maintain accurate clinical records of all patient consultations and related work

Review the latest guidance ensuring the practice conforms to regulations eg CQC etc.

Support in the delivery of enhanced services and other service requirements on behalf of the PCN

Participate in the management of patient complaints when requested to do so and participate in the identification of any necessary learning brought about through clinical incidents and near-miss events

Undertake all mandatory training and induction programmes

Contribute to and embrace the spectrum of clinical governance

Attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed

Contribute to supporting public health campaigns (e.g. flu)

Support delivery of QOF, incentive schemes, QIPP and other quality or cost effectiveness initiatives

Perform other general tasks as assigned.

Person Specification

Other requirements

Essential

• Flexibility to work outside of core General Practice hours
• Disclosure Barring Service (DBS) check
• Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own home

Skills

Essential

• Excellent communication skills (written and oral)
• Good IT skills
• Clear, polite telephone manner
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving and analytical skills
• Ability to follow policy and procedure
• Good organisational skills able to manage busy workload, prioritise work and have a good attention to detail

Desirable

• SystmOne user skills

Experience

Essential

• Experience of working in an NHS or Social Care organisation
• Experience of working in a busy administrative environment, delivering a full range of secretarial and administrative procedures
• Management of records and information in an office environment
• Previous experience of working in a customer focused environment
• Previous experience of working towards targets/deadlines
• Understanding of health and social care processes
• Knowledge of confidentiality and data protection legislation and is able to use discretion where necessary
• Knowledge & proficiency in use of relevant software packages eg Excel, Word, Outlook

Qualifications

Essential

• Educated to GCSE level or equivalent
• Passed training requirements as outlined by the Personalised Care Institute (or be prepared to enrol and complete next available course)
• Evidence of relevant and continuing professional development

Desirable

• NVQ Level 3 or equivalent qualification/experience within a business administration field.

Personal qualities

Essential

• 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

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

South Lincoln Healthcare

Address

c/o Church Walk Surgery

Drury Street

Metheringham

Lincolnshire

LN4 3EZ

Employer's website

https://www.southlincolnhealthcare.co.uk/ (Opens in a new tab)