Arbennek PCN is looking for an innovative and highly motivated person to join its team as a Care Coordinator.
The role, whilst supporting digital initiatives within the practice and PCN will be vital in ensuring that patients receive the best possible care and service supporting the coordination of all key activity including access to services, advice and information whilst ensuring that patient care planning is patient centered and timely.
We will be holding interviews for shortlisted candidates on 20.10.25
Main duties of the job
* Proactively identify and work with a cohort of patients to support their personalised care requirements
* Provide coordination and navigation support using digital tools to help patients access appropriate services
* Develop and maintain personalised care and support plans based on an individuals needs and what matters to them.
* Promote preventative heath care and continuity of care.
About us
Arbennek PCN is located in the central ICA within the Cornwalland Isles of Scilly Integrated Care System and has approximately 32,453 peopleregistered from 4 GP Practices Brannel Surgery, Clays Surgery, Probus Surgeryand Roseland Surgeries.
The post holder will work a majority of their time out of The Roseland Surgeries.
Job responsibilities
Job Purpose
The Care Coordinator role is seen as a criticaland evolving post to support the multi-disciplinary teams (MDTs) within the PCNto deliver effective, co-ordinated and personalised care for patients in carehomes and for a cohort of elderly and frail patients.
The post holder will work closely with teams tohelp and support the multi-disciplinary team (MDT) this will include theon-going patient case management. This will involve working with the GP surgeriesand linking in with a range of community health and social care services, carehomes and third party services.
The post holder will demonstrate excellentorganisational and communication skills, be flexible in their approach, able toexercise initiative and demonstrate consistently high standards ofprofessionalism. The post holder must at all times be aware of the need forconfidentiality and integrity. They will also need a basic knowledge of Healthand Social Care terminology and eligibility criteria and current teamstructures and pathways.
Key working relationships
Patients, patients families and carers
GPs, nurses and other practice staff
Care home managers, clinicians, carers and staff
Case Manager and Geriatrician
Community nurses and other allied health professionals
Community pharmacists and support staff
Responsibilities underpinning the role
The Care Coordinator has the following keyresponsibilities, in delivering health services:
To assist the team to develop one single personalisedcare and support plan for patients to be held on the patients medical recordsand in the care homes. Holistically bring together all of a patientsidentified care and support needs, and explore options to meet these with asingle personalised care and support plan (PCSP), in line with PCSP bestpractice, based on what matters to the person.
To assist the team to develop one single personalisedcare and support plan for patients to be held on the patients medical recordsand in the care homes. Holistically bring together all of a patientsidentified care and support needs, and explore options to meet these with asingle personalised care and support plan (PCSP), in line with PCSP bestpractice, based on what matters to the person.
Helppatients to manage their needs by answering queries, assisting with making/managing appointments, and ensuring that patients have good verbal or writteninformation to help them make choices about their care.
Providecoordination and navigation for patients and their carers across health andsocial care services, working closely with social prescribing link workers andother primary care professionals. Explore and assist people to access personalhealth budgets or appropriate benefits where eligible.
Supportpatients to utilise decision aids in preparation for a shared decision makingconversation.
Workwith GPs and other primary care professionals within the PCN to identify andmanage a caseload of patients, and where required and as appropriate, referpatients back to other health professionals within the PCN.
Raiseawareness within the PCN of shared decision making and decision support tools.Raise awareness of how to identify patients who may benefit from shareddecision making and support PCN staff and patients to be more prepared to haveshared decision making conversations.
To act as first point of contact for professionals,GPs, care homes, community services and the third sector.
Responsible for the organisation of MDT meetings and supportingthe coordination and delivery of MDTs within the PCN.
Responsiblefor a register of patients identified at PCN MDT coordinating patient careacross services and the PCN.
Reviewdischarge summaries and conduct post discharge follow up call to review patientsneeds and arrange a package of care if needed.
Managethe recall of patients in need of bloods/BPs and other diagnostic test formedication reviews and/or green eclipse alerts.
Toact as a support contact for elderly and frail patients.
Tosupport end of life care and palliative care.
Toprovide support for patients with learning disabilities.
Tofollow appropriate safeguarding procedures.
Administrative Reponsibilities
To work as a key member of the MDT to help support thedevelopment of effective MDT meetings.
Totake a lead in IT ensuring all MDT staff have access to Microsoft Teams andhave adequate equipment to participate in video meetings.
Lead on the IT facilitation of the MDT meetings usingMicrosoft teams including sending out invites to appropriate members of theMDT.
To take minutes of MDT meetings and ensure that actionpoints identified are recorded and followed up within a set timescale.
Under guidance from their line manager take initiativein the organisation and administration of MDT working to minimise the demandsupon the multidisciplinary team.
To work with the wider MDT to identify appropriate casemanagers* for high-risk patients to ensure that patients are reviewed, andanticipatory care plans are developed
Ensure that all patients Anticipatory Care Plans,diagnostics results and associated correspondence are available to the MDT,liaising with all agencies as appropriate, accessing IT systems to ensurerelevant information is available
To liaise with acute hospitals and coordinate thesharing of key information between the acute hospital teams and the MDT team.
Actas a non-clinical contact for the care home to assist with case management ofpatients at risk of admission; working with the ANP / GP to identify sources ofsupport in liaison with case managers.
Toaccurately read code and update/maintain patients records for anticipatorycare.
Toupdate care plan templates within Systm1 ensuring accuracy with read codesused.
Maintainan accurate record of two week wait referrals for practice audits.
Toprovide support with safeguarding admin (adults and child).
Under the guidance of case managers assist with thedischarge process to reduce length of stay in the acute / community hospitalsetting
Thislist is not exhaustive and may be subject to change.
Workforce Responsibility
The post holder must remain up to date with mandatorytraining as required
The post holder will be required to drive
The post holder may be required to undertake duties atany location in the community in order to meets service needs
Concentration required for data analysis, trackingpatients and meetings, frequent interruptions requiring attention andre-prioritisation of work
Input data for a significant period
Arbennek Healthcare is committed to an equal opportunities policythat affirms that all staff should be afforded equality of treatment andopportunity in employment irrespective of sexuality, marital status, race,religion/belief, ethnic origin, age, or disability. All staff are required toobserve this policy in their behaviour to fellow employees.
Confidentiality
All employees are required to observe the strictest confidencewith regard to any patient/client information that they may have access to, oraccidentally gain knowledge of, in the course of their duties.
All employees are required to observe the strictest confidenceregarding any information relating to the work of Arbennek Healthcare and itsemployees. You are required not to disclose any confidential information eitherduring or after your employment with Arbennek Healthcare, other than inaccordance with the relevant professional codes.
Failure to comply with these regulations whilst in the employmentof Arbennek Healthcare could result in action being taken.
Data Protection
All employees must adhere to the Arbennek Healthcare Policy on theProtection and use of Personal Information, which provides guidance on the useand disclosure of information. The practices of North Cornwall Coast also havea range of policies for the use of computer equipment and computer-generatedinformation. These policies detail the employees legal obligations and includereferences to current legislation.
Health and safety
Arbennek Healthcare expects all staff to have a commitment topromoting and maintaining a safe and healthy environment and be responsible fortheir own and others welfare.
You will be responsible for adopting the risk management cultureand ensuring that you identify and assess all risks to your systems, processesand environment and report such risks for inclusion within the risk register ofthe practices of Arbennek Healthcare. You will also attend mandatory andstatutory training, report all incidents/accidents, including near misses, andreport unsafe occurrences as laid down within the Incidents and AccidentsPolicy.
Other duties
The above job description is designedto give an overview of the tasks and responsibilities for this position; it isnot intended to be exhaustive. The Strategic Manager will meet annually withthe post holder to review and ensure that this position remains relevant and inaccordance with the evolving needs of the PCN.
Person Specification
Qualifications
* Qualified NVQ level 2 (or equivalent) Health and Social care
* Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
* Experience of administrative duties
* Computer literate and proficient in the use of Microsoft packages and other software.
* Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
* Able to prioritise and manage own workload
* Able to deal with service users sensitively
* Able to work as part of team
* Strong analytical and judgement skills.
* Conscientious, hardworking and self-motivated to work with minimal supervision
* Professional attitude and assertive approach
* Committed to development both personally and for the organisation
* Ability to meet deadlines and work under pressure
* Qualified NVQ level 3 (or equivalent) Health and Social care
* Experience of arranging meetings/ minute taking
* Experience providing signposting and advice
* Understanding of health and social care processes
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.
#J-18808-Ljbffr