PCN Care Co-ordinator (Proactive Care)

Job description

Job responsibilities

The Care Coordinator will work as an integral part of the PCN and will be based within both Practices within it. They will work with the MDT One Team members including their PCN PAC team colleagues (who will provide cover for the postholder's annual leave etc), to maximise the use of resource, avoid duplication and share information.

This role will include:

1. Supporting the Nurse Specialist/s in Proactive Care.

2. Holding and maintaining the daily Multi Disciplinary Team (MDT) One Team caseload.

3. Supporting Practices in the identification and maintenance of the proactive care caseload.

4. Facilitating early supported discharge through the management of the daily One Team MDT meeting, proactively working with the named GP to operate a pull model and post discharge follow up model

5. Supporting the Named GP in organising urgent care to support people in the community and reduce avoidable admissions, ensuring the best outcome.

6. Providing co-ordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals to help ensure patients receive a joined up service and the most appropriate support.

7. Providing an advice and signposting service for service users, carers and professionals.

8. Co-ordinating and arranging MDT meetings with older people and their carers to facilitate holistic person centred care planning, with regular reviews. Ensuring that each person is supported to achieve their goals and encouraged to take the lead in managing their own care and well-being.

9. Ensuring that allocated patients are able to access services available in the community both free and where charges apply - based on the Co-ordinators detailed knowledge of the relevant access arrangements, eligibility criteria and service content. To connect the services that already exists locally both statutory and voluntary, so that services wrap-around the patient.

10. Working with people with a range of needs, dealing with issues ranging from social isolation and keeping people engaged in their community, to prevent unnecessary admission to hospital or care homes.

11. Reviewing and updating personalised care and support plans at regular intervals and ensure these are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED (system) codes.

12. Assisting people to access an assessment for Adult Social Care where appropriate, and providing information in connection with personal budgets

13. Reviewing all elderly/complex patients post discharge notifications to identify those requiring urgent community follow up by the relevant team.

Person Specification

Experience

Essential

• Experience of working in a health or social care setting in a support role in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience of working within multi-professional team environments
• Experience of supporting elderly people/people with complex conditions, their families and carers in a related role
• Experience of data collection, running reports and using tools to measure the impact of services

Desirable

• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
• Experience or training in personalised care and support planning
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Knowledge and Skills

Essential

• Excellent communication skills (written and oral)
• Strong IT skills including competency in the use of Office and Outlook
• Clear, polite telephone manner
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving & analytical skills
• Ability to follow policy and procedure

Desirable

• EMIS (clinical system) user skills
• Understanding of clinical coding
• Knowledge of the personalised care approach
• Knowledge of how the NHS works, including primary care and PCNs
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes

Personal Qualities

Essential

• Polite and confident
• Flexible and cooperative
• Motivated
• Forward thinker
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure

Other requirements

Essential

• Disclosure Barring Service (DBS) check
• Access to own transport and ability to travel across the PCN on a regular basis

Desirable

• Flexibility to work outside of core office hours

Qualifications

Essential

• Educated to GSCE or equivalent standard A-C /Grade 4 or above in English and Maths
• Demonstrable commitment to professional and personal development

Desirable

• A-Level standard /NVQ Level 3 in adult care - advanced level or equivalent

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.

Employer details

Employer name

Tadley Medical Partnership

Address

Holmwood Health Centre

Franklin Avenue

Tadley

Hampshire

RG26 4ER

United Kingdom

Employer's website

https://www.tadleymedical.co.uk/ (Opens in a new tab)