Job summary
Job SummaryPrimary Care Networks have been established to bring together resources from arange of different organisations to deliver holistic integrated health, social andcare support for their local population.As a Care Coordinator you will work as a key part of the primary care network(PCN) multidisciplinary team. You will be the key link to the people whose careyou are supporting, operating as a go to person to ensure that their care isseamless, they are active decision makers in their own care, and that everyoneinvolved is working together. Care Coordinators provide extra time, capacity andexpertise to support patients in preparing for or in following up clinicalconversations they have with primary care professionals.You will work closely with the GPs and other primary care professionals withinthe PCN to identify and manage a caseload of identified patients, making surethat appropriate support is made available to them and their carers, and ensuringthat their changing needs are addressed.Using agreed templates and assessment tools you will ensure an outcome-basedcare plan is co-produced with each person. You will review plans at regularintervals to capture progress, ensure they remain appropriate for the individualand identify any input required from wider team members including healthcarespecialists.
Main duties of the job
Primary Duties and Areas of Responsibility
Take overall responsibility for coordination and delivery of the weekly PCNled MDT meetings. A key role of the Care Coordinator will be to schedulethe weekly MDT meetings, manage the meeting agenda items; ensuringthat all new referrals are identified, and information circulated to teammembers in advance of the meeting. Utilise population health intelligence and PCN / Partner data to proactivelyidentify and work with a cohort of patients to deliver personalised care.
Support patients to utilise decision aids in preparation for a shareddecision-making conversation.
Holistically bring together all of a persons identified care and supportneeds, and explore options to meet these within a single personalised careand support plan (PCSP), in line with PCSP best practice, based on whatmatters to the person.
Help people to manage their needs through answering queries, makingand managing appointments, and ensuring that people have good qualitywritten or verbal information to help them make choices about their care.
Support people to take up training and employment, and to accessappropriate benefits where eligible.
Support people to understand their level of knowledge, skills andconfidence (their Activation level) when engaging with their health andwellbeing, including through the use of the Patient Activation Measure.
About us
Newly formed Primary Care Network (PCN) linked to 4 GP Surgery sites, team is growing and evolving and now seeking more staff to deliver the care services to our patients.
Developing new and exciting additional roles to support GP's and clinical teams at enhancing patient services in the local community.
Vibrant, friendly working atmosphere with great career progression opportunities.
Job description
Job responsibilities
Take overall responsibility for coordination and delivery of the weekly PCNled MDT meetings. A key role of the Care Coordinator will be to schedulethe weekly MDT meetings, manage the meeting agenda items; ensuringthat all new referrals are identified, and information circulated to teammembers in advance of the meeting. Utilise population health intelligence and PCN / Partner data to proactivelyidentify and work with a cohort of patients to deliver personalised care.
Support patients to utilise decision aids in preparation for a shareddecision-making conversation.
Holistically bring together all of a persons identified care and supportneeds, and explore options to meet these within a single personalised careand support plan (PCSP), in line with PCSP best practice, based on whatmatters to the person.
Help people to manage their needs through answering queries, makingand managing appointments, and ensuring that people have good qualitywritten or verbal information to help them make choices about their care.
Support people to take up training and employment, and to accessappropriate benefits where eligible.
Support people to understand their level of knowledge, skills andconfidence (their Activation level) when engaging with their health andwellbeing, including through the use of the Patient Activation Measure.
Assist people to access self-management education courses, peer supportor interventions that support them in their health and wellbeing andincrease their activation level.
Explore and assist people to access personal health budgets whereappropriate.
Provide coordination and navigation for people and their carers acrosshealth and care services, working closely with social prescribing linkworkers, health and wellbeing coaches, and other primary careprofessionals.
Work with the GPs and other primary care professionals within the PCN toidentify and manage a caseload of patients, and where required and asappropriate, refer people back to other health professionals within thePCN.
Raise awareness within the PCN of shared decision making and decisionsupport tools.
Raise awareness of how to identify patients who may benefit from shareddecision making and support PCN staff and patients to be more preparedto have shared decision-making conversations.
Person Specification
Qualifications
Essential
1. GCSE or equivalent grade C level qualification in Maths and English.
2. Experience Minimum of 1 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
3. Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
4. Experience providing advice/signposting to patients.
5. Experience of undertaking quality improvement activity.
6. Excellent organisational and administration skills.
7. Ability to analyse and interpret information and present results in a clear and concise manner.
8. Able to prioritise and manage own workload.
Desirable
9. Experience of working in a multi-disciplinary setting where influence and negotiation is required.
10. Experience of using technology and digital tools to support health and wellbeing.
11. Experience of co-production with patients or service-users.
12. Skills and Knowledge Excellent influencing and negotiating skills.
Experience
Essential
13. Experience working within a healthcare setting and interacting with patients.