PCN Care Co-ordinator (Cardiovascular Disease)
Information:
This job is now closed
Job summary
The Rural West Primary Care Network (PCN)is looking to recruit a second cardiovascular disease (CVD) Care Co-ordinator,to workalongside the existing CVD Care Co-ordinator and as part of our PCN's widerteam to enhance our friendly, busy network ofpractices. Themain purpose of this role is to provide administrative support to patients acrossthe Rural West PCN with long-term Conditions (LTC); specifically, those peoplewith cardiovascular disease (CVD), high blood pressure, heart disease andstrokes. This is a non-clinical role, but the successful candidate will play akey role in proactively identifying and working with these patients, theirfamilies and carers to improve the ongoing management of their condition.
Main duties of the job
The postholder will work closely with the GPs, nurses and the wider practice teams,to make sure that patients with CVD receive the very best care and reviewsaccording to individual need. The role involves giving patients the opportunityfor health reviews to manage and improve their long-term health and wellbeing,as well as encouraging those less engaged. This non-clinical role isadministrative rather than patient facing, but patient contact by telephone isa key element, as the role involves organising appointments directly with thepatients. The postholder will provide support to patients as a regular point ofcontact for CVD-related needs, as well as supporting the clinical teams as theyprovide patient care. This will include managing blood pressure informationcoming into our sites.
Thepostholder will enable patients to access the services and support required to meet their health and wellbeing needs. They will work alongside our Social Prescribers and Health & Wellbeing Coaches to provide an all-encompassingapproach to personalised care and will also work with a diverse range of peoplefrom different cultural and social backgrounds.
Applicants will need excellent administration, interpersonal and communication skills and be organised, motivated and empathetic. The ability to work confidently and effectively in a varied and sometimes challenging environment is essential. The postholder will preferably have experience of working in a primary care setting.
About us
The Rural West Primary Care Network (PCN)is friendly busy network of practices, comprising two GP Partnerships: TadleyMedical Partnership and Watership Down Health with surgeries in Kingsclere,Overton, Oakley and Tadley in North Hampshire. The role is based within both Partnerships' practices in the PCN.
The work is interesting and varied and thepost holder will have the benefit of working with our supportive and friendlymulti-disciplinary teams to promote excellent patient care. We are alwayslooking to improve the quality of our services and everyone is encouraged to sharegreat ideas. The position offers a competitive salary dependent on experienceand access to the NHS pension scheme, together with flexibility of working.
Job responsibilities
The Care Co-ordinatorwill work as an integral part of the PCNs multidisciplinary team (MDTs), workingalongside the existing CVD Care Co-ordinator and with the Social Prescribers andHealth and Wellbeing Coaches to provide an all-encompassing approach topersonalised care, and promoting and embedding the personalised care approachacross the PCN. They will be based within both Practices within it.
The post holder will:
1. Workcollaboratively with GPs and other primary care professionals within the PCN toproactively identify and manage a caseload of patients with long-term healthconditions, specifically those people with Cardiovascular Disease (CVD)and where appropriate, refer back to other health professionals within the PCN.This will involve regularly running reports from our clinical systems i.e. EMIS.
2.Provide proactive support to the Practices CVD teams and the PCN toensure achievement of the new CVD specific QOF targets
3. Participatein the daily and weekly Multi-Disciplinary Team (MDT) OneTeam meetings with the PCN team and community services if required.
4. Provideco-ordination and navigation for people and their carers across health and careservices, working closely with social prescribing link workers, health andwellbeing coaches, and other primary care professionals to help ensure patientsreceive a joined up service and the most appropriate support.
5. Workwith people, their families and carers to improve their understanding of thepatients condition and support them to develop and review personalised careand support plans to manage their needs and achieve better healthcare outcomes.
6. Ensure that allocated patients are able to accessservices available in the community both free and where charges apply - basedon the Co-ordinators detailed knowledge of the relevant access arrangements,eligibility criteria and service content. To connect the services that alreadyexists locally both statutory and voluntary, so that services wrap-aroundthe patient.
7. Helppeople to manage their needs through answering queries, making and managingappointments, and ensuring that people have good quality written or verbalinformation to help them make choices about their care.Refer onwards to social prescribing link workers and healthand wellbeing coaches where required.
8. Assist people to access an assessment for Adult SocialCare where appropriate and provide information in connection with personalbudgets.
9. Conductfollow-ups on communications from out of hospital and in-patient services.
10. Maintain records of referrals andinterventions to enable monitoring and evaluation of the service.
11. Supportthe PCN in developing communication channels between GPs, people and theirfamilies and carers and other agencies.
12. Supportpractices to keep care records up to date by identifying and updating missingor out-of-date information about the persons circumstances.
13. Contribute to risk and impact assessments,monitoring and evaluations of the service.
14. Reviewand update personalised care and support plans at regular intervals and ensurethese are communicated to the GP and any other professionals involved in thepersons care and uploaded to therelevant online care records, with activity recorded using the relevant SNOMED (system)codes.
15. Raiseawareness of how to identify patients who may benefit from shared decisionmaking and support PCN staff and patients to be more prepared to have shareddecision making conversations.
16. Takereferrals for individuals or proactively identify people who could benefit fromsupport through care co-ordination.
Please note that we use a number of IT tools,including development AI, and this requires an openness, enthusiasm andinterest in technology.
Person Specification
Knowledge and Skills
* Excellent communication skills (written and oral)
* Strong IT skills including competency in the use of Office and Outlook
* Clear, polite telephone manner
* Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
* Understanding of, and commitment to, equality, diversity and inclusion
* Strong organisational skills, including planning, prioritising, time management and record keeping
* Basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social
* Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
* Ability to work as a team member and autonomously
* Good interpersonal skills
* Problem solving & analytical skills
* Ability to follow policy and procedure
* Understanding of clinical coding
* Knowledge of the personalised care approach
* Knowledge of how the NHS works, including primary care and PCNs
* Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
Personal Qualities
* Polite and confident
* Flexible and cooperative
* Motivated
* Forward thinker
* High levels of integrity and loyalty
* Sensitive and empathetic in distressing situations
* Ability to work under pressure
Other requirements
* Access to own transport and ability to travel across the PCN on a regular basis
* Flexibility to work outside of core office hours
Experience
* Experience of working in a health or social care setting in a support role in direct contact with people, families or carers (in a paid or voluntary capacity),particularly those patients with CVD
* Experience of working within multi-professional team environments
* Experience of data collection, running reports and using tools to measure the impact of services
* Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
* Experience or training in personalised care and support planning
* Experience of working with elderly or vulnerable people, including those with CVD, complying with best practice and relevant legislation
* Experience of supporting people, their families and carers in a related role, particularly those with CVD
Qualifications
* Qualifications
* Educated to GSCE or equivalent standard A-C /Grade 4 or above in English and Maths
* Demonstrable commitment to professional and personal development
* A-Level standard /NVQ Level 3 in adult care - advanced level or equivalent
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.
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