Job responsibilities
The post holder is a member of the Primary Care Network
(PCN) Additional Roles team providing a central co-ordination role for patient
care planning across the network practices. The Care Coordinator will work
autonomously within the community and will have a key role in supporting
delivery of the new Network Contract DES Service Specifications.
The Care Coordinators role will support the PCN in
coordinating all key activity for patients including access to services,
advice, and ensure that personalised care planning is patient centred. They
focus delivery of the Comprehensive Model for Personalised Care to reflect
local priorities, health inequalities and population health risk
stratification.
This role will work within our network providing a
central co-ordination role for patient care planning. Co-ordinate care packages
for patients as identified by the healthcare professional across health, social
care, and mental health as appropriate, providing a single-point of access for
staff and service users, actively managing patients care plan delivery.
Care Coordinators, review patients needs and help them
access the services and support they require to understand and manage their own
health and wellbeing, referring to social prescribing link workers and other
health care professionals where appropriate.
Job
Responsibilities:
Provide coordination and navigation for people
and their carers across health and care services, helping to ensure patients
receive a joined-up service and the most appropriate support.
Facilitate and ensure the effective delivery of
patient-centred, personalised health and social care plans for patients,
monitoring progress and reporting outcomes, contributing to patient reviews and
care planning within appropriate time frames.
Explain the management of a patients pathway to
clinical staff, liaising between services and service users, contacting
services using the appropriate procedures/referral mechanisms.
Work closely with all relevant care agencies
(primary care, secondary care, community services, Mental Health, Social
Services, Ambulance Service, Voluntary Services, and other relevant service
providers) to ensure a coordinated patient care plan, without requiring a
further referral from the GP.
Collect data on patients/carers for recognised
outcome measure and document for service interpretation. Ensure all patient
notes are updated/read coded to reflect any changes, including details on their
care plans.
Developing and maintaining the PCN Directory of
Services which contains a centralised contact list for relevant care providers
including secondary, community and diagnostic providers to support referrals.
Act as the single point of contact for the PCN
and establish systems and processes which will ensure a timely and appropriate
response to queries from clinicians and other stakeholders.
Ensure regular and consistent communication with
the referrer regarding patient progress and any complications or guidance.
Raise awareness of health promotion and NHS
health checks in practices and with members of the local community.
Monitor referrals to ensure tasks are completed
and care delivered by keeping in regular telephone contact.
Refer to PCN social prescribing link workers where
a patient is identified as potentially benefitting from this service.
Bring together all a persons identified care
and support needs and explore their options to meet these into a single
personalised care and support plan, in line with best practice.
Raise awareness of shared decision-making and
decision support tools, assist people to be more prepared to have a shared
decision-making conversation.
Support the coordination and delivery of the PCN
led Multi-disciplinary Team (MDT) meetings including collating patients for
discussion, capturing minutes/actions, and updating care plans accordingly.
Working with the health care professionals who
lead the care home weekly ward rounds to identify patients for acute and
routine review.
Arranging care home ward rounds with the
relevant healthcare professionals and care home managers.
Establishing processes for patients to be
reviewed during the care home ward round.
Ensuring that all care home residents have a
personalised care plan in place and that this is reviewed appropriately in line
with the patients health needs.
Scoping and arranging community outreach
sessions with the PCN team and linking in with the Digital and Communications
Manager for promotion of the events and capturing case studies as a result.
Liaising with local community providers to
schedule and coordinate the community outreach sessions including forward
planning dates across the network, booking venues and arranging the teams
rotas accordingly.
Participate in community outreach events to
raise awareness of national/local health campaigns to promote health and
wellbeing to the local population.
Help people transition seamlessly between
services and support them to navigate through the health and care system.
Utilise population health intelligence to
proactively identify and work with a cohort of patients to deliver personalised
care.
Support patients to utilise decision aids in
preparation for a shared decision-making conversation.
Holistically bring together all a persons
identified care and support needs and explore options to meet these within a
single personalised care and support plan.
Help people to manage their needs through
answering queries, making, and managing appointments, and ensuring that people
have a good quality written or verbal to help them make choices about their
care.
Raising awareness within the PCN and its member
practices of shared decision-making and decision support tools.
Explore and assist people to access personal
health budgets where appropriate.
Utilising SystmOne to set up searches, data
collection and creating rotas for the clinical team.
Reviewing and maintaining the clinical stock
including protective personal equipment, stationary and medical equipment.
Ordering as necessary.
Obtaining and sharing a calendar of national
health campaigns and sourcing resources as appropriate.
Supporting the PCNs protected learning sessions
with arranging speakers, caterers, issuing certificate of attendance and
general on the day facilitation.
Supporting the PCNs Patient Participation Group
(PPG) with taking minutes, following up actions, distributing meeting papers
and working with the team to create a forward planner of agenda items for
discussion.
