PCN Care Co-Ordinator

Job summary

The Care Coordinator role is seen as a critical and evolving post to support the PCN multi-disciplinary team to deliver effective, co-ordinated and personalised care for patients. This role will specifically focus on patients living in care homes, supported living environments and elderly and frail patients living independently in their own homes

The post holder will support people at home to live in the least restrictive way and those living in care homes and supported living environments to remain empowered and ensure that their voices are heard

To act as the first point of contact for GPs, Adult Social Care, Care Homes, other Community Services and VCSE organisations regarding matters relating to a persons care and support needs

The post holder will work in a supportive capacity with both the PCN Wellbeing team, assisting with administrative tasks as required. Including: personalised care and support plans (PCSPs), referrals, minute-taking and signposting

The role will also involve working in a supportive capacity with the teams in each GP Practice and linking in with a range of community health and social care services, care homes and the VSCE

Main duties of the job

Work with GPs and other Primary Care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the PCN and / or practices

Help patients to manage their needs by answering queries and ensuring that patients have good verbal or written information to help them make informed choices about their care

Provide co-ordination and navigation for patients and their carers across health and social care services, working closely with Primary Care Health professionals, Adult Social Care and Social Prescribing Link Workers

Work collaboratively with patients to write PCSPs and if applicable and the person has consented, ensure this information is shared with all relevant parties - families, carers and other health care professionals, holistically bring together all the patients identified care and support needs

Provide support for carers and link in with appropriate local services

Raise awareness within the PCN of shared decision making and decision support tools. 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

To follow appropriate safeguarding procedures

To attend MDTs and minute meetings where appropriate

About us

North Cornwall Coast Primary Care Network is a progressive, successful network of three North Cornwall Coast GP practices covering circa 21,000 patients. Building on established links with Cornwall ICA and partner organisations, we are developing an ambitious joint plan to the improve health and well-being for our patients.