The successful candidate will be based at Sundon Park HealthCentre, Tenth Avenue, Luton. This is the Hub for Hatters Health PCN a Networkof five friendly pro-active practices. They will be caring, dedicated, reliableand person-focussed and enjoy working with a wide range of people. They willhave good written and verbal communication skills and strong organisational andtime management skills. They will be highly motivated and proactive with aflexible attitude, keen to work and learn as part of a team and committed toproviding people, their families and carers with high quality support. This role is intended to support the effective delivery of enhancedaccess as well as focusing on the PCN's cancer related objectives. Please note that the role of a care coordinator is not aclinical role.
Main duties of the job
Rota management for enhanced access delivery
Gather data for regular reporting of enhanced access activity
To identify rota anomalies and escalate to appropriate colleagues
To support delivery of cancer project outcomes
Making and managing appointments for patients, related toprimary, secondary, community, local authority, statutory, and voluntaryorganisations
Keep accurate and up-to-date records of contacts,appropriately using GP and other records systems relevant to the role, adheringto information governance and data protection legislation
To take referrals for individuals or proactively identifypeople who could benefit from support through care coordination
About us
Hatters Health PCN is a collaborative of 5 friendly and proactive surgeries in Luton. We have a strong ethos of delivering high quality patient centred care. We are recognised as a learning organisation and recognise the importance of supporting the development of our teams
Job responsibilities
Job TitlePCN Care-Coordinator
Responsible toPCN Business Manager
Accountable toPCN Clinical Director
Hours of work37.5 Hours per week, 1 year fixed term
Salary TBC
Purpose of the role
Care Coordinators play an important role within a PCN toproactively identify and work with people, including those with long-termconditions, cancer, and frailty to provide coordination and navigation of careand support across health and care services. They work closely with GPs andpractice teams to manage a caseload of patients, acting as a central point ofcontact to ensure appropriate support is made available to them and theircarers; supporting them to understand and manage their condition and ensuringtheir changing needs are addressed. This is achieved by bringing together allthe information about a persons identified care and support needs andexploring options to meet these within a single personalised care and supportplan, based on what matters to the person. Care coordinators review patientsneeds and help them access the services and support they require to understandand manage their own health and wellbeing, referring to social prescribing linkworkers, health and wellbeing coaches, and other professionals whereappropriate.
The successful candidate will be based at Sundon Park HealthCentre, Tenth Avenue, Luton. This is the Hub for Hatters Health PCN a Networkof five friendly pro-active practices. They will be caring, dedicated, reliableand person-focussed and enjoy working with a wide range of people. They willhave good written and verbal communication skills and strong organisational andtime management skills. They will be highly motivated and proactive with aflexible attitude, keen to work and learn as part of a team and committed toproviding people, their families and carers with high quality support.
This role is intended to support the effective delivery of enhancedaccess as well as focusing on the PCNs Cancer related objectives.
Please note that the role of a care coordinator is not aclinical role.
Key responsibilities
To support the efficient delivery of enhancedaccess by supporting daily operational delivery. Ensuring adequate staffing andensuring a proactive approach to booking appointments.
To support data gathering for monthly reportingon enhanced access
Work with people, their families and carers toimprove their understanding of the patients condition and support them todevelop and review personalised care and support plans to manage their needsand achieve better healthcare outcomes.
Help people to manage their needs throughanswering queries, making and managing appointments, and ensuring that peoplehave good quality written or verbal information to help them make choices abouttheir care.
Assist people to access self-managementeducation courses, peer support, health coaching and other interventions thatsupport them in their health and wellbeing, and increase their levels ofknowledge, skills and confidence in managing their health.
Provide coordination and navigation for peopleand their carers across health and care services, working closely with socialprescribing link workers, health and wellbeing coaches, and other primary careprofessionals; helping to ensure patients receive a joined-up service and themost appropriate support.
Work collaboratively with GPs and other primarycare professionals within the PCN to proactively identify and manage acaseload, which may include patients with long-term health conditions, andwhere appropriate, refer back to other health professionals within the PCN.
Raise awareness of how to identify patients whomay benefit from shared decision making and support PCN staff and patients tobe more prepared to have shared decision-making conversations.
Explore and assist people to access a personalhealth budget where appropriate.
Support PCNs in developing communicationchannels between GPs, people and their families and carers and other agencies
Identify unpaid carers and help them accessservices to support them
Maintain records of referrals and interventionsto enable monitoring and evaluation
Support practices to keep care records up todate by identifying and updating missing or out-of-date information
Contribute to risk and impact assessments,monitoring and evaluations of the service
Work with PCN Manager to further develop therole.
Key Tasks
Rota management for enhanced access delivery
Gather data for regular reporting of enhanced accessactivity
To identify rota anomalies and escalate toappropriate colleagues
To support delivery of cancer project outcomes
Making and managing appointments for patients,related to primary, secondary, community, local authority, statutory, andvoluntary organisations
Keep accurate and up-to-date records ofcontacts, appropriately using GP and other records systems relevant to therole, adhering to information governance and data protection legislation
To take referrals for individuals or proactivelyidentify people who could benefit from support through care coordination
Proactively identify patients who would benefitfrom improved quality of care provision/ long term condition management
Have a positive, empathetic and responsiveconversation with the person and their family and carer(s) about their needs
Develop an in-depth knowledge of the localhealth and care infrastructure and know how and when to enable people to accesssupport and services that are right for them
Use tools to measure peoples levels ofknowledge, skills and confidence in managing their health and to tailor supportto them accordingly
Support people to develop, implement and reviewpersonalised care and support plans, with activity recorded using the relevantSNOMED codes within patient records
Help people transition seamlessly betweensecondary and community care services, conducting follow-up appointments, andsupporting people to navigate through wider the health and care system
Refer onwards to social prescribing link workersand health and wellbeing coaches where required
Regularly liaise with the range ofmultidisciplinary professionals and colleagues involved in the persons care,facilitating a coordinated approach and ensuring everyone is kept up to date sothat any issues or concerns can be appropriately addressed and supported
Actively participate in multidisciplinary teammeetings in the PCN as and when appropriate
Encourage people, their families and carers toprovide feedback and to share their stories about the impact of carecoordination on their lives
Undertake continual personal and professionaldevelopment, taking an active part in reviewing and developing the role andresponsibilities, and provide evidence of learning activity as required
Adhere to organisational policies andprocedures, including confidentiality, safeguarding, lone working, informationgovernance, equality, diversity and inclusion training and health and safety
Establish strong working relationships with GPsand practice teams and work collaboratively with other care coordinators,social prescribing link workers and health and wellbeing coaches, supportingeach other, respecting each others views
Act as a champion for personalised care andshared decision making within the PCN
Demonstrate a flexible attitude and be preparedto carry out other duties as may be reasonably required from time to timewithin the general character of the post or the level of responsibility of therole, ensuring that work is delivered in a timely and effective manner
Contribute to the development of policies andplans relating to equality, diversity and reduction of health inequalities
Work in accordance with the practices and PCNspolicies and procedures
Contribute to the wider aims and objectives ofthe PCN to improve and support primary care
Person Specification
Qualifications
* NVQ LEVEL 3 IN ADULT CARE
Experience
* Experience of data collection
* Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
* Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
* Experience of supporting people, their families and carers in a related role
* Knowledge of the personalised care approach
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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