Job responsibilities
Work with people, their families and carers, to improve their understanding of their condition.
Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Provide coordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.
Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
Support the coordination and delivery of multidisciplinary teams with the PCN.
Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations.
Take referrals or proactively identify people who could benefit from support through care coordination.
Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them.
Support people to develop and implement personalised care and support plans.
Review and update personalised care and support plans at regular intervals.
Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
Make and manage appointments for patients, related to primary care.
Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system.
Refer onwards to social prescribing link workers and other services where required and to clinical colleagues where there is an unaddressed clinical need.
Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
Actively participate in multidisciplinary team meetings in the PCN.
Identify when action or additional support is needed, alerting a named contact in addition to relevant professionals, and highlighting any safety concerns.
Record what interventions are used to support people, and how people are developing on their health and care journey.
Work with your supervising GP / ANP to undertake continual personal and professional development, taking an active part in reviewing yearly progress, and developing the roles and responsibilities and developing clear plans to achieve results within priorities set by others.
Work with your supervising GP / ANP to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.
Involved in one-to-one meetings with line manager regularly to discuss targets and outcomes achieved.
Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers, and the wider PCN team, supporting each other, respecting each others views and meeting regularly as a team.
Act as a champion for personalised care and shared decision making within the PCN.
Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning.
Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities.
Adhere to organisational, practices and PCN policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Contribute to the wider aims and objectives of the PCN to improve and support primary care.
