PCN Long Term Conditions Care Coordinator

Job description

Job responsibilities

Purpose of the role

Care coordinators play an important role within a PCN to proactively identify and work with people, including the 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.

This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

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 professionals where appropriate.

Care coordinators could provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.

In this role, you will be required to support the Practice & PCN to deliver all the Quality and Outcomes and Impact and Investment Fund key performance indicators (KPIs) which will be reviewed each year. As they are based on prevention, support and clinical care, these KPIs directly support patients with their health and care needs aiding to reduce unwarranted variation within the Practice and across the PCN.

The successful candidate will be first point of contact for patients within the Primary Care Access Hub. The role includes providing front desk services including booking, cancelling and rearranging appointments and answering queries in person and on the phone. They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.

This role is intended to become an integral part of the Practice's and PCNs multidisciplinary team, working alongside Practice staff and PCN staff such as social prescribing link workers to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

Please note that the role of a care coordinator is not a clinical role.

Key responsibilities

Help people to manage their needs through active information co-ordination, working with clinical lead staff/others, calling patients, answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care supporting QOF & PCN IIF KPIs.

Ensure consistent, high quality and comprehensive monitoring and recording of information onto SysytmOne as well as other templates as required to ensure data capture meets the KPIs as per the MOU agreed with the Practice.

Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing.

Provide coordination and navigation for people and their carers across health and care services, working closely with other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.

Work collaboratively with GPs, ACPs, Nurses and other primary care professionals within the Practice to proactively identify and manage patients, which may include patients with long-term health conditions, QOF indicators and IIF indicators and where appropriate, refer back to other health professionals within the PCN.

Support the coordination and delivery of multidisciplinary teams with the Practice & PCN.

Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.

Explore and assist people to access a personal health budget where appropriate.

Support Practice & PCN in developing communication channels between GPs, people and their families and carers and other agencies.

Signpost and support patients to other services such as the social prescribing service to help patients access services to support them.

Support the practice & PCN to keep care records up-to-date by identifying and updating missing or out-of-date information;

Key Deliverables information

Quality & Outcomes Framework as set out at Practice level

Impact & Investment Fund as set out at PCN level

Person Specification

Experience

Essential

• Experience of working with the general public
• Experience of data capture, collection, reporting and actioning
• Understand the Quality and Outcomes (QOF) Framework and PCN Impact & Investment Fund (IIF) is desirable
• Knowledge of the personalised care approach
• 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
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
• Ability to recognise and work within limits of competence and seek advice when needed
• Understanding of the needs of patients including long term conditions particularly in relation to promoting their independence
• Knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social

Desirable

• Experience of working in General Practice or Primary Care
• Experience of working on SystmOne is desirable

Qualifications

Essential

• See full job description and specification attached.
• In summary: ability to actively listen, empathise with people and provide support in a non-judgemental way. Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential. Ability to communicate effectively both in writing and verbally with people, their families and carers. Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines. Ability to work flexibly and enthusiastically within a team or on own initiative. Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook

Desirable

• Experience of working within general practice or primary care experience of working on Systm1 is desirable but not essential.

Personal qualities and attributes

Essential

• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, clinicians, partner agencies and stakeholders
• Ability to identify risk and assess / manage risk when working with individuals
• Have a strong awareness and understanding of when it is appropriate or necessary to refer people to a clinician, when what the person needs is beyond the scope of the care coordinator role
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• Ability to demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• High level of written and verbal communication skills
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Ability to provide motivational coaching to support peoples behaviour change
• Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety

Expected attitude and behaviours

Essential

• High service delivery work ethic being flexible across the work in the organisation. A can do attitude , be patient focused always having a customer mind set. To be a team player across the practice / Erewash Health Partnership. Have good attendance and be resilient.

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

Erewash Health Partnership

Address

The Dales Medical Centre

The Dales

West Hallam

Ilkeston

Derbyshire

DE7 6JA

Employer's website

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