Proactive Care Coordinator - South West Shropshire PCN

Job summary

South West Shropshire PCN is working with partners in Shropshire Telford and Wrekin ICS to develop a Proactive Care service, which aims to work with individuals living with frailty and/or deprivation to identify and meet their health and care needs, and to support them to maintain their own health and wellbeing for longer.

Main duties of the job

The duties and responsibilities to be undertaken by the Proactive Care Coordinator may include any or all of the items in the following list. Duties may be varied from time to time under the direction of the PCN management team.

• Work with PCN Digital Care Coordinator, practices and ICB to use data and risk stratification tools to identify and clinically validate the cohort of people who might benefit most from the proactive care approach.
• Contact identified individuals to explain the programme and gain their consent to take part.
• Refer individuals who wish to take part to the MDT for holistic needs assessment and formation of a Personalised Care and Support Plan.
• Arrange and lead MDT meetings to discuss how best to meet the identified needs of individuals in the programme.
• Coordinate the delivery of support and interventions, including supporting individuals to take action to meet their own needs, signposting to other relevant services where appropriate.
• Acting as first point of contact for individuals on the programme, helping them to contact appropriate professionals and services when needs arise.
• Support evaluation and reporting on the progress of the programme and developing the service in response to findings of that evaluation.

About us

South West Shropshire PCN is made up of 6 practices covering over 36500 patients, over a large rural catchment area. The population is generally older than average, with a higher proportion of frail patients. Rural deprivation is a significant issue.

Our Mission: Protecting and strengthening primary care in South West Shropshire, to enable improved mental and physical health and wellbeing in our communities.

Our Vision: We will collaborate and innovate to provide modern sustainable general practice to our communities.

We will work with and coordinate health and social care services around practices and communities.

We will improve children's and adults mental health.

If you have any questions regarding this vacancy, please contact:

Deborah Shepherd, PCN Clinical Director: Deborah.shepherd@nhs.net

or

Debbie Davies, PCN manager: Deborah.davies45@nhs.net