Care Co-ordinator

Job description

Job responsibilities

Job description

Key Responsibilities

Work with the PCN Practices to Co-ordinate and deliver the health inequalities and Cancer areas of the network DES

To take referrals for individuals or proactively identify people who could benefit from support through care coordination.

Act as a point of contact between GP patients and carers and other agencies.

Liaise with GPs and practice teams to identify patients who are elderly frail or who have long term health needs and support

Work with the multi-disciplinary team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.

Provide these cohorts of people signposting to identified services in order to maintain their independence and improve their health and well being.

Assist with personal care plans for individual patients, ensuring preventative actions are detailed to support the appropriate use of services.

Communicate the care plan to the GP and any other professionals involved in the persons care and upload to the relevant records.

Ensure that identified patients receive the right level of help at the right time and help them to experience a joined up service by liaising with relevant Organisations.

Liaise with other agencies, Primary, Secondary and specialist care services to ensure timely and appropriate engagement as required.

Support patients to access community care assessments as well as carers assessments.

Identify unpaid carers and direct them to access services as appropriate to provide them with support.

Follow up on communications from out of hospital and in-patient services regarding changes in condition of patients to support the practice to respond proactively to potentially unmet needs.

Undertake visits or telephone contact to manage patients on the PCNs case load following any unplanned hospital admissions where appropriate.

To attend multi-disciplinary meetings plus any other meetings where there is a need to discuss patients on case load. Updates between meetings to be shared with the Practices.

To run regular patient searches using Emis in order to have an up to date record of progress of achievement of Key Performance Indicators.

Support the PCN in providing KPI reports for submission as requested.

Collate data for submission to the ICB (Integrated Care Board) or NHSE

Arrange meeting and produce minutes of those meetings

Work with the PCN Operations Manager to produce policies and protocols

Person Specification

Qualifications

Essential

• You will have experience working within healthcare or the voluntary / community sector, supporting vulnerable groups
• Excellent IT Skills inc. Microsoft Office and experience with GP Clinical System (Emis or equivalent)
• You will have strong listening and communication skills
• Ability to work well in a team; however, also able to work independently without supervision
• You will be able to review and improve working practices with shared experience across the PCN

Desirable

• Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field

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

Cannock Medical Group in partnership with Cannock Villages PCN

Address

High Street Surgery

Cheslyn Hay

Cannock

Staffordshire

WS6 7AB

Employer's website

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