PCN Care Co-ordinator

Job description

Job responsibilities

Please see attached job description for full details.

Key Responsibilities

Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.

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.

Support people 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 (PAM).

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.

Support people to take up training and employment, and to access appropriate benefits where eligible.

Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.

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 patients to be more prepared to have shared decision-making conversations.

Explore and assist people to access a personal health budget where appropriate.

Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours;

Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies;

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

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

Maintain records of referrals and interventions to enable monitoring and evaluation of the service;

Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances;

Contribute to risk and impact assessments, monitoring and evaluations of the service;

Work with commissioners, integrated locality teams and other agencies to support and further develop the role.

Person Specification

Qualifications

Essential

• Demonstrable commitment to professional and personal development.
• Ability to use Microsoft Office applications
• Word, Excel, PowerPoint, Outlook

Desirable

• NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards

Experience

Essential

• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity).
• Experience of working within multi- professional team environments.
• Experience of supporting people, their families and carers in a related role.
• Experience of data collection and using tools to measure the impact of services.

Desirable

• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health /health improvement.
• Experience or training in personalised care and support planning.
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.

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

MKGP Plus Ltd

Address

Whalley Drive

Bletchley

Milton Keynes

Buckinghamshire

MK3 6EN

Employer's website

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