Job responsibilities
Job
Description - Hatters Health PCN Care-Coordinator
Job TitlePCN Care-Coordinator
Responsible toPCN Business Manager
Accountable toPCN Clinical Director
Hours of work37.5 Hours per week, 1 year fixed term
Salary TBC
Purpose of the role
Care Coordinators play an important role within a PCN to
proactively identify and work with people, including those with long-term
conditions, cancer, and frailty to provide coordination and navigation of care
and support across health and care services. They work closely with GPs and
practice teams to manage a caseload of patients, acting as a central point of
contact to ensure appropriate support is made available to them and their
carers; supporting them to understand and manage their condition and ensuring
their changing needs are addressed. This is achieved by bringing together all
the information about a persons identified care and support needs and
exploring options to meet these within a single personalised care and support
plan, based on what matters to the person. Care coordinators review patients
needs and help them access the services and support they require to understand
and manage their own health and wellbeing, referring to social prescribing link
workers, health and wellbeing coaches, and other professionals where
appropriate.
The successful candidate will be based at Sundon Park Health
Centre, Tenth Avenue, Luton. This is the Hub for Hatters Health PCN a Network
of five friendly pro-active practices. They will be caring, dedicated, reliable
and person-focussed and enjoy working with a wide range of people. They will
have good written and verbal communication skills and strong organisational and
time management skills. They will be highly motivated and proactive with a
flexible attitude, keen to work and learn as part of a team and committed to
providing people, their families and carers with high quality support.
This role is intended to support the effective delivery of enhanced
access as well as focusing on the PCNs Cancer related objectives.
Please note that the role of a care coordinator is not a
clinical role.
Key responsibilities
To support the efficient delivery of enhanced
access by supporting daily operational delivery. Ensuring adequate staffing and
ensuring a proactive approach to booking appointments.
To support data gathering for monthly reporting
on enhanced access
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.
Assist people to access self-management
education courses, peer support, health coaching and other interventions that
support them in their health and wellbeing, and increase their levels of
knowledge, skills and confidence in managing their health.
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.
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.
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
Maintain records of referrals and interventions
to enable monitoring and evaluation
Support practices to keep care records up to
date by identifying and updating missing or out-of-date information
Contribute to risk and impact assessments,
monitoring and evaluations of the service
Work with PCN Manager to further develop the
role.
Key Tasks
Rota management for enhanced access delivery
Gather data for regular reporting of enhanced access
activity
To identify rota anomalies and escalate to
appropriate colleagues
To support delivery of cancer project outcomes
Making and managing appointments for patients,
related to primary, secondary, community, local authority, statutory, and
voluntary organisations
Keep accurate and up-to-date records of
contacts, appropriately using GP and other records systems relevant to the
role, adhering to information governance and data protection legislation
To take referrals for individuals or proactively
identify people who could benefit from support through care coordination
Proactively identify patients who would benefit
from improved quality of care provision/ long term condition management
Have a positive, empathetic and responsive
conversation with the person and their family and carer(s) about their needs
Develop an in-depth knowledge of the local
health and care infrastructure and know how and when to enable people to access
support and services that are right for them
Use tools to measure peoples levels of
knowledge, skills and confidence in managing their health and to tailor support
to them accordingly
Support people to develop, implement and review
personalised care and support plans, with activity recorded using the relevant
SNOMED codes within patient records
Help people transition seamlessly between
secondary and community care services, conducting follow-up appointments, and
supporting people to navigate through wider the health and care system
Refer onwards to social prescribing link workers
and health and wellbeing coaches where required
Regularly liaise with the range of
multidisciplinary professionals and colleagues involved in the persons care,
facilitating a coordinated approach and ensuring everyone is kept up to date so
that any issues or concerns can be appropriately addressed and supported
Actively participate in multidisciplinary team
meetings in the PCN as and when appropriate
Encourage people, their families and carers to
provide feedback and to share their stories about the impact of care
coordination on their lives
Undertake continual personal and professional
development, taking an active part in reviewing and developing the role and
responsibilities, and provide evidence of learning activity as required
Adhere to organisational policies and
procedures, including confidentiality, safeguarding, lone working, information
governance, equality, diversity and inclusion training and health and safety
Establish strong working relationships with GPs
and practice teams and work collaboratively with other care coordinators,
social prescribing link workers and health and wellbeing coaches, supporting
each other, respecting each others views
Act as a champion for personalised care and
shared decision making within the PCN
Demonstrate a flexible attitude and be prepared
to carry out other duties as may be reasonably required from time to time
within the general character of the post or the level of responsibility of the
role, ensuring that work is delivered in a timely and effective manner
Contribute to the development of policies and
plans relating to equality, diversity and reduction of health inequalities
Work in accordance with the practices and PCNs
policies and procedures
Contribute to the wider aims and objectives of
the PCN to improve and support primary care
