Job summary
Whitby Coast and Moors Primary Care Network are looking to recruit an enthusiastic and compassionate Patient Care Coordinator. Our PCN is setting up a new multidisciplinary holistic care team to provide dedicated support and care for patients with complex needs. The team will care primarily, but not exclusively, for older adults.
You will have the opportunity to share in the development of this new team which will focus on health, wellbeing and independence.
You will need to have clarity of professional identity and be comfortable working with a degree of uncertainty as new services are tested and developed.
In this new team there will be plenty of opportunity to use your service development, leadership and excellent coordination skills as you work with others to improve outcomes for patients.
If you are excited by the chance to work in a brand new team designed to make a real difference to patients' lives, and based in a beautiful area, please consider this role.
Main duties of the job
This role is part of our new complex care team offering holistic care to patients with complex needs, often elderly patients living, for example, with frailty, long term conditions, or social and mental health needs.
We are looking for Patient Care Coordinator who is enthusiastic about playing an active part in our complex care team that will work with our evolving integrated neighbourhood team (INT). This is an exciting role, and we are looking for a candidate who will exemplify good team working and effective respectful communication with all team colleagues across professional boundaries such as primary care, community services, social services, mental health, and the voluntary sector. We regard empathy for our older patients and a desire to be guided by what matters most to them to be important attributes.
Role to be responsible for the implementation of processes for the effective management of patients with long-term conditions using evidence-based practice including care for elderly and housebound patients. Working as a member of the practice multidisciplinary team.
About us
Whitby Coast and Moors PCN comprises 4 GP practices in Whitby and the surrounding area. Our member practices are Whitby Group Practice, Esk Valley Medical Practice, Staithes Surgery and Sleights and Sandsend Medical Practice. Our population faces particular challenges relating to higher than average chronic disease, coastal deprivation and rural isolation.
As a forward-thinking PCN we are open to exploring new ways of working together and see the development of our new team as a fantastic opportunity to improve the health of our population and make a real difference to our patients' lives.
Our well-run practices are located in a stunningly beautiful area where staff turnover rates are low. We are proud to achieve consistently high feedback from our patients. We welcome any informal enquiries and visits relating to this exciting new role.
Job description
Job responsibilities
The following are the core responsibilities of the PCN Patient Care Coordinator in delivering health services. There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels:
- Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
- Support patients to utilise decision aids in preparation for a shared decision-making conversation
- 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 following the NHS Comprehensive Care Model. See also YouTube NHS Comprehensive Personalised Care Model - Explainer Animation
- 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 to make choices about their care, using tools to understand peoples level of knowledge and confidence in skills in managing their own health
- Support people to take up training and employment and to accessappropriate benefits where eligible
- 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
- Explore and assist people to access personal health budgets where appropriate
- 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
- Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients and, where required and as appropriate, refer people back to other health professionals within the PCN
- Raise awareness within the PCN of shared decision making and decision support tools
- 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
- Support the coordination and delivery of MDTs within the PCN
- Undertake all mandatory training and induction programmes
- Contribute to and embrace the spectrum of clinical governance
- Develop the PCC role through participation in training and service redesign activities
- Attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed
- Maintain a clean, tidy, effective working area at all times
Job description
Job responsibilities
The following are the core responsibilities of the PCN Patient Care Coordinator in delivering health services. There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels:
- Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
- Support patients to utilise decision aids in preparation for a shared decision-making conversation
- 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 following the NHS Comprehensive Care Model. See also YouTube NHS Comprehensive Personalised Care Model - Explainer Animation
- 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 to make choices about their care, using tools to understand peoples level of knowledge and confidence in skills in managing their own health
- Support people to take up training and employment and to accessappropriate benefits where eligible
- 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
- Explore and assist people to access personal health budgets where appropriate
- 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
- Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients and, where required and as appropriate, refer people back to other health professionals within the PCN
- Raise awareness within the PCN of shared decision making and decision support tools
- 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
- Support the coordination and delivery of MDTs within the PCN
- Undertake all mandatory training and induction programmes
- Contribute to and embrace the spectrum of clinical governance
- Develop the PCC role through participation in training and service redesign activities
- Attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed
- Maintain a clean, tidy, effective working area at all times
Person Specification
Qualifications
Essential
- GCSE grade C or above, or equivalent in English and Maths
- Office experience in private or health sector
- Professional contact with the General Public
- Customer Services experience
Desirable
- NVQ level 2 in Health and Social Care
- Previous NHS experience
- Experience of using practice clinical systems
Person Specification
Qualifications
Essential
- GCSE grade C or above, or equivalent in English and Maths
- Office experience in private or health sector
- Professional contact with the General Public
- Customer Services experience
Desirable
- NVQ level 2 in Health and Social Care
- Previous NHS experience
- Experience of using practice clinical systems
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.
