Job responsibilities
As a PCN Health Inequalities and
Long Term Conditions Care Coordinator, you will play a vital role in helping individuals
with health inequalities regain stability and improve their quality of life.
Your main and overall responsibilities will include:
Assessment and Planning:Conduct
assessments of patients needs and develop Personalised Care Support Plans
(PCSPs).
Needs Assistance:Ensure
patients are getting their annual health checks completed, supported in
participation of national vaccination and cancer screening programmes, and
assisted in accessing any other services that they may need
Advocacy:Advocate
on behalf of patients to access essential services, benefits, and housing
opportunities. This includes supporting them to feel comfortable in attending
their appointments & making reasonable adjustments.
Referral Services:Connect
patients to relevant community resources, health and social care, local
carers support service, community navigation and working with and other healthcare
& mental health services
Documentation:Maintain
accurate and up-to-date patient records and progress reports.
The Care Coordinator responsibilities include but are not limited to
the following:
To
work with the GPs and other primary care professionals within the PCN to
identify and manage a caseload of patients
In
collaboration with clinicians, administrative and reception team
colleagues, to help patients with complex needs navigate the health and
care system. This includes
helping them 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
patients to utilise decision aids, help create single personalised care
and support plans, in line with best practice.
Holistically
bring together all of a persons identified care and support needs, and
explore options to meet these within a single personalised care and
support plan (PCSP), in line with PCSP best practice, based on what
matters to the person.
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)
Provide
coordination and navigation for people and their carers across health
and care services, including the use of digital tools.
Support
people to take up training and employment, and to access appropriate
benefits where eligible;
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
Explore
and assist people to access personal health budgets, where appropriate.
Work
closely with social prescribing link workers, health and wellbeing coaches,
and other primary care professionals.
Other key relationships include: City and Hackney Neighbourhood team,
GP Confederation, social care, secondary care (Homerton and ELFT), community
services, community and Clinical Pharmacists, City and Hackney CCG, Hackney
Community and Voluntary sector and fellow care coordinators.
Support
the Clinical directors in the delivery of the DES specifications and support
practices to reach proactive care targets
Support
practices in engaging patients in initiatives such as cancer screening, LTC
checks, vaccination & immunisation uptake.
Engage, attend and link in with the PCN
community navigation team and the wider neighbourhood MDT meetings.
EDUCATION, LEARNING AND DEVELOPMENT
There is a requirement to comply
with all organisational and statutory requirements (e.g. health and safety,
infection control, equality and diversity, confidentiality, safeguarding adults
and children, information governance).
You will engage with appropriate
training for Care Coordinators as set out by the Personalised Care Institute
There is a requirement to engage
in annual appraisal, developing objectives to inform a Personal Development
Plan, which may include 360-degree appraisal and use of patient feedback.
Support the practice staff and
respond to requests for advice and assistance.
Undertake additional training
where necessary to provide enhanced services and participate in training
programmes implemented by the PCN/practices as part of this employment.
CONFIDENTIALITY
In the performance of the duties
outlined in this Job Description, the post-holder will have access to
confidential information relating to patients and their carers, practice staff
and other healthcare workers. They may also have access to information relating
to the network. All information is to be regarded as strictly confidential.
Maintain confidentiality of any
information concerning patients in accordance with current policy on
information governance.
Demonstrate respect for privacy
and confidentiality in all interactions with patients and the public.
DATA
PROTECTION
If you are required to obtain,
process and/or use information held electronically you should do 'it in a fair
and lawful way. You should hold data only for the specific registered purpose
and not use or disclose it in any way incompatible with such a purpose. Data
must only be disclosed to authorised persons or organisations as instructed.
SAFEGUARDING ADULTS AND CHILDREN
The postholder has a duty to
safeguard and promote the welfare of vulnerable adults and children.
When adults or children and/or
their carers use primary care services, it is essential that all adult and
child protection concerns are both recognised and acted on appropriately.
The postholder has a
responsibility to ensure they are familiar with and follow local policies in
relation to safeguarding vulnerable adults and that they follow the local child
protection procedures and any supplementary guidance.
The postholder has a
responsibility to support appropriate investigations either internally or
externally.
To ensure the postholder is
equipped to carry out their duties effectively, they must also attend
vulnerable adult and child protection training and updates at the competency
level appropriate to the work they do and in accordance with the local vulnerable
adult and child protection training guidance.
EQUALITY AND DIVERSITY
Supports the equality, diversity,
and rights of patients, carers and colleagues, that includes:
Acting in a way that recognise the
importance of peoples rights, interpreting them in a way that is consistent
with practice procedures and policies, and current legislation
Respects the privacy, dignity,
needs and beliefs of patients, carers and colleagues
FLEXIBILITY
This job description is not
intended to be exhaustive. The care coordinator role within general practice is
new and there will be extensive learning and adaptation throughout the contract
period. The post-holder will be expected to adopt a flexible attitude towards
the duties outlined which may be subject to amendment at any time in
consultation with the post-holder and in line with the needs of the
organisation.
The post holder may be required to
fulfil other duties, as agreed with the line manager/ clinical director to meet
the needs of the organisation. This will involve travel to other sites within
the organisation
There will be some evening and
weekend working requirements, which will be negotiated locally.
