Overview
Join to apply for the Long Term Conditions Care Co-Ordinator role at NHS.
The Long-term Condition Care Co-ordinators play an important role within a Primary Care Network (PCN) to proactively identify and work with people 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.
They review patients needs, help them access services and support to understand and manage their own health and wellbeing, and may refer to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate. The aim is to help people improve their quality of life.
Details
Based in a local cluster of General Practices as part of Carlisle Primary Care Network (PCN). The role requires independence, reliability and strong communication and organisational skills. It is intended to become an integral part of the PCN multidisciplinary team, collaborating with a wide range of professionals and partner organisations.
Employer: Eden Medical Group (Carlisle PCN Hub, Carlisle, Cumbria, CA2 7AJ). Website: https://www.edenmedicalgroup.co.uk/
Job Responsibilities
* Provide support to patients aged 18 years and over with long-term conditions, engaging them in their care and encouraging improved outcomes.
* Support PCN practices to deliver against the PCN Direct Enhanced Service (DES) specification and contribute to meeting QOF and KPI criteria.
* Work with clinicians and primary care professionals to proactively identify and manage a caseload of patients, referring to other health professionals within the PCN as appropriate.
* Coordinate and deliver multidisciplinary team efforts within PCN practices.
* Promote shared decision making and prepare patients and staff to engage in these conversations.
* Develop and maintain personalised care and support plans, updating records with appropriate SNOMED codes and ensuring information governance compliance.
* Coordinate care across primary, secondary, community and other services; manage appointments and facilitate transitions between care settings.
* Refer patients to social prescribing link workers and health and wellbeing coaches when required.
* Maintain up-to-date records, monitor service delivery, and contribute to risk assessments and evaluations.
* Collaborate with commissioners, integrated locality teams and other agencies to develop and strengthen the role.
Main Duties
* Enable access to personalised care and support.
* Take referrals or proactively identify individuals who could benefit from care coordination.
* Engage with patients and families to understand needs and support the development of personalised care plans.
* Increase patient understanding of how to manage health and wellbeing, providing guidance and information.
* Know the local health and care infrastructure and how to access appropriate services.
* Measure knowledge, skills and confidence to tailor support; ensure care plans are communicated to clinicians and uploaded to care records.
* Coordinate and integrate care; manage appointments with various health and social care providers.
* Support people in navigating the health and care system and follow up after clinical conversations as needed.
* Maintain records of interventions and facilitate timely communication among professionals.
* Participate in multidisciplinary team meetings and identify when additional support is required.
* Adhere to information governance, confidentiality, safeguarding, and health and safety policies.
Person Specification
Essential
* Active listening, empathy and the ability to provide personalised support non-judgementally.
* Culturally sensitive service delivery and commitment to reducing health inequalities.
* Strong communication and organisational skills; ability to work under pressure and as part of a team.
* Knowledge of policies and procedures including confidentiality, safeguarding, information governance, equality and health & safety.
* Understanding of the needs of older people and adults with disabilities/long-term conditions and promotion of independence.
Desirable
* Motivational coaching to support behaviour change.
Experience
Essential
* Knowledge of personalised care approach and wider determinants of health.
* Understanding of equality, diversity and inclusion.
* Strong organisational, planning, time management and record-keeping skills.
* Knowledge of how the NHS works, including primary care and PCNs.
* Ability to recognise limits of competence and seek advice when needed.
* Understanding of the needs of older people/adults with disabilities/long-term conditions to promote independence.
Desirable
* Knowledge of safeguarding policies; basic knowledge of long-term conditions and their complexities.
Qualifications
Essential
* GCSE level education.
Desirable
* NVQ or equivalent in administration / customer services / Health & Social Care.
Other
Disclosure and Barring Service check required. This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions Order) and will require a DBS disclosure.
Job Location: Carlisle PCN Hub, Carlisle, Cumbria, CA2 7AJ
Notes
Dates and posting notes, and extraneous referral information from the original listing have been omitted to focus on role content and requirements.
#J-18808-Ljbffr