Overview
Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, 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 person\'s 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.
Primary Responsibilities
1. Enable access to personalised care and support
- Take referrals for individuals or proactively identify people who could benefit from support through care coordination
- 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 people\'s levels of knowledge, skills and confidence in managing their health and tailor support accordingly
- Support people to develop and implement personalised care and support plans
- Review and update personalised care and support plans at regular intervals
- Ensure personalised care and support plans are communicated to the GP and other professionals involved in the person\'s care and uploaded to the relevant online care records, with activity recorded using the SNOMED code
1. Coordinate and integrate care
- Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations
- Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate the wider health and care system
- Refer onwards to social prescribing link workers and health and wellbeing coaches where required
- Regularly liaise with multidisciplinary professionals involved in the person\'s care, facilitating a coordinated approach and ensuring everyone is kept up to date
- Actively participate in multidisciplinary team meetings in the PCN as appropriate
- Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns
- Record interventions used to support people and how they are developing on their health and care journey
- Keep accurate and up-to-date records of contacts, adhering to information governance and data protection legislation
- Work sensitively with people, their families and carers to capture key information and track the impact of care coordination on health and wellbeing
- Encourage feedback and sharing of stories about the impact of care coordination
- Record and collate information according to agreed protocols and contribute to evaluation reports for monitoring and quality improvement
1. Professional development
- Work with a named clinical point of contact for advice and support
- Undertake continual personal and professional development and provide evidence of learning activity as required
1. Miscellaneous
- Establish strong working relationships with GPs and practice teams; collaborate with other care coordinators, social prescribing link workers and health and wellbeing coaches
- 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 reasonably required
- Identify opportunities and gaps in the service and contribute to business planning; develop policies and plans relating to equality, diversity and reducing health inequalities
- Work in accordance with practice and PCN policies and procedures; contribute to wider aims and objectives of the PCN to improve primary care
- Adhere to organisational policies and procedures including confidentiality, safeguarding, information governance, equality, diversity and inclusion training and health and safety
Key Tasks
1. 1. Enable access to personalised care and support
- Take referrals or proactively identify people who could benefit from support
- Engage in empathetic conversations with the person and their family and carers about their needs
- Help people understand how to manage and develop health and wellbeing through advice and guidance
- Build knowledge of local services to enable access to the right support
- Use tools to tailor support to individual knowledge, skills and confidence
- Support development and implementation of personalised care and support plans; review at regular intervals
- Ensure plans are communicated to the GP and other professionals and uploaded to care records with appropriate coding
1. 2. Coordinate and integrate care
- Manage appointments across primary, secondary, community, local authority, statutory and voluntary sectors
- Support transitions between secondary and community care and aid navigation through the system
- Refer to social prescribing link workers and health and wellbeing coaches where required
- Liaise with multidisciplinary professionals to maintain a coordinated approach
- Participate in multidisciplinary team meetings as appropriate
- Flag safety concerns and escalate as needed
- Record interventions and track progress; maintain up-to-date records and ensure information governance
- Collect feedback and contribute to service evaluation
1. 3. Professional development
- Work with a named clinical point of contact for ongoing advice and support
- Pursue ongoing professional development and provide evidence of learning
1. 4. Miscellaneous
- Build strong relationships with GPs, practice teams and other care coordinators; support a collaborative team environment
- Promote personalised care and shared decision making
- Maintain flexibility and willingness to take on related duties as required
- Support equality, diversity and inclusion and maintain confidentiality and safeguarding standards
Requirements and Qualifications
Experience – Essential: Experience in multiprofessional team environments; experience in data collection and measuring service impact
Desirable: direct care coordination experience; working with elderly or vulnerable people; experience in personalised care and support planning
Personal Qualities – Essential: polite, flexible, motivated, proactive, empathetic, strong integrity, ability to work under pressure, effective communication, commitment to development, and culturally sensitive service delivery
Skills – Essential: excellent communication, strong IT, MS Office/Outlook/EMIS or Vision experience, time management, teamwork and problem solving
Knowledge – Essential: knowledge of personalised care approach, wider determinants of health, equality and inclusion, NHS structure, safeguarding policies; understanding of needs of older people and those with disabilities
Qualifications – Essential: proficient in MS Office and web-based services
Other – Disclosure and Barring Service check required
Employer details
Greenwich PCN Alliance Ltd, Memorial Hospital, London SE18 3RG
Note: This role is not clinical; it is aimed at integrating care coordination within the PCN multidisciplinary team.
About us
Greenwich PCN Alliance Limited has been running since 2020 and consists of four PCNs: Blackheath and Charlton PCN, Eltham PCN, Heritage PCN and Unity PCN. Our aim is to support the improvement of primary care across Greenwich by providing support to PCNs and recruiting Additional Roles via the ARRS.
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