Kernow Health CIC
This job is now closed
The East Cornwall Primary Care Network goal is a leading innovator in the new and developing Primary Care Network model
We are looking for enthusiastic, innovative and forward thinking care coordinators to join our Network of GP practices across East Cornwall. We see our PCN Care Co-ordinator team as a key clinical resource in delivering excellence in patient health care and to help support our GP practices in ensuring all patients receive the best possible care and service
If you are looking for a new challenge where you see and support patients with their healthcare needs, as an integral part of a GP practice and PCN team then this role is for you!
This is an exciting opportunity to provide support to GP practices and patients within the locality. As a PCN Care Co-ordinator in an East Cornwall practice you will manage your own workload to assist the practice team with co-ordination and access to services, advice, and information, and ensuring health and care planning is timely, efficient, and patient-centred. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patient’s journey through primary care. You will work closely with our social prescribing link workers and other agencies in order to meet the personalised health care agenda.
Full time or part time hours considered.
Main duties of the job
We will provide you with professional mentoring and bespoke coaching support so you can expand your skills and confidence to best support your patients. You will work as part of a team across the PCN, supporting practices to offer patients a bespoke care package that is designed around the individual patient’s needs.
East Cornwall has also been recently awarded Primary Care Network of the Year, recognising the locality’s forward thinking and ambition to deliver excellent clinical care. The locality is committed to developing an exceptional integrated care team approach to better support people within the community setting. This will bring together a range of health and social care professionals to work together to provide enhanced personalised and preventative care for their local community. If you are interested in working as part of a clinical team within general practice, then we would be excited to hear from you.
The East Cornwall locality General Practices have formed a provider company Kernow Health East Ltd which will operate the East Cornwall Primary Care Network (PCN). The neighbourhoods you will be recruited to include the Saltash Practices (Saltash Health Centre and Port View), the Rame Peninsula (Rame Group Practice), St Germans (Quay Lane Surgery), Liskeard (Oaktree and Rosedean) and Looe (Old Bridge Surgery). You will be based across the locality’s GP practices providing clinical pharmacy support as part of the practice clinical teams, working either in practice or remotely as part of a clinical hub.
As PCN Care Coordinator you will work as a key part of the primary care network (PCN) multi-disciplinary team. You will ensure care is seamless and that everyone involved is working together. You will provide the capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with PCN primary care professionals.
You will support the Network in developing a support to Care homes within the PCN and the ongoing work towards the COVID Vaccination Programme. You will assist PCN provider practices in our ambition to improve the quality and continuity of care by acting as a point of contact and coordinating annual reviews for patients with 1 or more chronic conditions, participating in meetings and timely intervention as part of the MDT for each practice and across the PCN.
Your role is an essential part of our evolving dynamic and forward-thinking PCN, working to provide enhanced care experience to patients in line with a with a view to improving health inequalities. Other duties may include:
• Act as a point of contact between GP, patients and carers and other agencies
• Liaise with GPs and practice teams to identify patients who are elderly, frail or who have long term health needs and support
• Develop and embed the use of Group Consultations to help support the care arrangements for patients with long term conditions.
• Support patients to access community care assessments as well as carers assessments
• Undertake visits or telephone contact to manage patients on the PCNs case load following any unplanned hospital admissions where appropriate.
• Where necessary, participate in MDT meetings to discuss patients actively being managed by the Care Homes Team and any other patients from the PCNs case load needing discussion.
• Raise awareness of health promotion & screening such as NHS Health Checks and LD Health Checks in practices and coordinate invitations to ensure targets are achieved on a practice and PCN level
• Assist and manage recall system for chronic diseases inc acting as a point of contact for any queries regarding routine annual reviews.
• Ongoing monitoring of PCN requirements inc. IIF and QOF across the PCN practices.
• Run Audits and searches where necessary to identify patients for review.
• Assist and Co-ordinate PCN clinics where necessary, and contact identified patients with appointments
• Manage patient initiated calls for help/signposting etc., ensuring patients are directed to appropriate service inc liaising with other PCN staff e.g. Social Prescribers
• Document and monitor aspects of patient co-ordination and service delivery supporting data collection and audit using the practices clinical system
• Demonstrate the ability to recognise and respond appropriately when faced with a sudden deterioration or emergency situation, alerting the team or enabling a rapid response
• Support and raise awareness national screening and immunisation programmes and encourage uptake
• Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact
• Work closely with and refer to PCN social prescribing link workers where a patient is identified as potentially benefitting from this service.
Please find the full job description attached for more details on key roles and responsibilities.
Skills and Abilities
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.
Certificate of Sponsorship
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).