Job responsibilities
JOB DESCRIPTION
JOB TITLE: Care Coordinator
LOCATION: Across three GP Practices and community settings
HOURS OF WORK: 37.5 hours (job share will be considered)
SALARY: £23,500 - £27,000 (depending on experience)
OVERVIEW
The post holder will work alongside clinicians and other staff across East Warrington Network as part of a multi-disciplinary team. This means that you will work across the three GP practices. East Warrington PCN is looking to grow their care coordinator team who already work closely with our diverse patient population, as well as key stakeholders. The care coordination role supports the PCN leadership team and GPs in coordinating all key activity including improving access to services, providing advice and information, and ensuring health and care planning is timely, efficient, and patient-centred. You will work on a range of targeted interventions, focusing on specific cohorts of patients.
The PCN is headed by our committed Clinical Director, Strategic Manager, Digital Transformation Manager, Practice Managers and GP members.
Main duties and responsibilities will include:
Providing coordination and navigation for both staff and patients, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals, acting as a point of contact to help deal with incoming queries.
Actively signpost patients to the most appropriate clinician, liaising with clinical teams or other outside agencies to implement treatment plans as necessary.
Identifying patients from a task list to arrange follow-up appointments and review of care plans.
Arrange appointments for patients as directed by clinicians, following identification of urgent and non-urgent clinical needs.
Holistically bring together a persons identified care and support needs, exploring options to meet these within a personalised care plan based on what matters to the person, communicating this to other health care professionals in a clear and concise way.
Assist people to access third sector services, peer support or interventions that support them to take more control of their health and well-being.
Ensure that people have good quality written or verbal information to help them make choices about their care, using tools to understand peoples level of knowledge, confidence in skills in managing their own health.
Embrace the coordinator aspect of your role within the PCNs wellbeing team, working with other roles in the PCN to improve our patients health and wellbeing; these include Social Prescribing Link Workers, Health & Wellbeing Coach, Frailty Care Coordinator and Mental Health Practitioners.
Visit patients in community, home or care home settings to assess and discuss their care needs, involving family/carers as appropriate.
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
Support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers.
Explore and assist people to access personal health budgets where appropriate
Build strong and collaborative relationships with local community and voluntary organisations, seeking new opportunities.
Run audits and searches where necessary to identify patients for review.
Refer patients to the appropriate team member and make referrals on behalf of the team.
Monitor referrals to ensure tasks are completed and care is delivered as planned by maintaining regular telephone contact.
Support the PCN to deliver and report on quality metrics, such as QOF, KPIs and locally commissioned enhanced services by documenting and monitoring aspects of patient coordination and service delivery
Support the coordination and delivery of MDTs within the PCN, working as part of the wider holistic team to provide support as necessary.
Build and maintain relationships with members of the local support team including named GPs, pharmacists, community nursing teams, therapists, dementia nurses etc.
Regularly attend the PCN meetings to update the wider team on your work.
Work with clinical and digital system colleagues to implement and operate technology solutions/equipment to enable self-taking of health diagnostics.
Support the development of a PCN-wide Winter Pressure plans, including the rollout of flu and covid vaccinations.
Raise awareness within the PCN of shared decision-making and decision support tools; and
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
Supporting the PCN with delivery of the Enhanced Access service as required
Children, Young Persons and Families Care Coordination duties and responsibilities.
The PCN is currently working on an exciting project in collaboration with our secondary care mental health provider, to develop a Children and Young Persons Primary Care Mental Health Service across our three GP Practices, it is expected that this role will support delivery of this service.
Duties will include, but not be limited to: -
Support the CYPMH Pathway by identifying child and their families for the service, this will involve working closely with the primary care mental health team.
Be the practice representative for the service, co-ordinating and liaising between the practices and the mental health teams, supporting children and their families to receive a high-standard or care.
Working with children, their families and carers to improve their understanding of the childs needs and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Help children and their families 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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health
Assist children and their families to access self-management education courses, peer support or interventions that support them in their wellbeing
Provide coordination and navigation for children, their families and their carers across health and care services, education and schools, working closely with the PCN team 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 children with long-term health problems, and where appropriate, refer to other health professionals within the PCN.
Actively signpost children and their families to the best service that is relevant in accordance with the childs needs.
Cancer Care Coordination duties and responsibilities
Provide admin support for Gold Standard Framework (GSF) meetings and support families/carers.
Support practices to deliver their quality improvement plans for early cancer diagnosis.
Support practices to improve cancer screening uptake, liaising with external agencies as appropriate
Work off task lists to proactively identify and work with patients newly diagnosed with cancer and on the cancer register to deliver personalised care.
Ensure patients receive a Cancer Care review in line with national defined timescales and targets.
Other: Any responsibility identified during the course of the job.
About the Candidate
We are looking for someone who is dynamic and can work autonomously or part of a Team. Our GP Practices are very busy and therefore this role will require someone who can work autonomously, think on their feet, be responsive, supportive and a dedicated self-starter. You must be enthusiastic and committed to providing a high-level service to both our patients and our three (very different) GP Practices.
The successful candidate will have great negotiation and communication skills, along with empathy and must be a peoples person. You will also require an understanding of primary care and community health services.
This role will continue to evolve over time.
