Job summary
The PCN Care
Co-ordinator plays an important role within a PCN to proactively identify and
work with people to provide coordination and navigation of care and support
across health and care services.
The postholder will deliver NHS
Health Checks in line with national guidance and provide administrative
follow-up to ensure continuity of care. They will also support general hub
coordination and front, patient navigation, and population health initiatives.
The role includes participation in a
rota covering extended access hours to include two weekday evenings (currently Wednesday and
Thursday until 8 pm) andSaturdays (9am 5pm)
Main duties of the job
NHS Health Check Delivery
o
Deliver NHS Health Checks for eligible patients,
carrying our near point of care testing, including lifestyle
assessments, and cardiovascular risk scoring.
o
Provide brief interventions and health promotion
advice tailored to individual risk profiles.
o
Accurately document clinical data in patient
records using appropriate systems.
Administrative Follow-Up
o
Manage post-check communications, including
results, follow-up bookings, and referrals.
o
Ensure accurate coding and data entry in line
with NHS Health Check programme requirements.
o
Support reporting and audit processes to
maintain service quality
Care Coordination & Hub Support
o
Act as first point of contact for patients
accessing the Health & Wellbeing Hub (face-to-face, phone, email).
o
Book patients into appropriate services and
signpost to community resources.
o
Promote hub services and events, including via
social media platforms.
Teamwork & Rota Commitment
o
Work collaboratively within the Care
Co-ordinator team, supporting shared goals and mutual learning.
o
Participate in extended access rota, including
evenings and Saturdays.
o
Ensure consistent service delivery across all
sessions.
Service Development & Governance
o
Maintain accurate records and adhere to data
protection and safeguarding policies.
o
Support delivery of PCN Network DES, enhanced
services, and population health initiatives.
About us
Bridgwater Bay Primary Care Network
(PCN) is the largest PCN in Somerset with 9 GP practices supporting 85,000
patients from a diverse population spread across town and rural locations.
As a PCN we are forward
thinking, innovate and driven to deliver the best patient care for our
population. This includes health population management, and this role ties in
with supporting that and tracking the improvements we can make to patients
lives. The role will be based at
Victoria Park Health and Wellbeing Hub which is a shared space between the
Primary Care Network and Somerset Foundation Trust.
Job description
Job responsibilities
1. NHS Health Check Delivery
2. Administrative Follow-Up
3. Care Coordination & Hub
Support
4. Teamwork & Rota Commitment
5. Service Development &
Governance
Professional
development
Work within a clinical team point for advice and
support.
Undertake continual personal and professional
development, taking an active part in reviewing and developing the role and
responsibilities, and provide evidence of learning activity as required;
Adhere to organisational policies and procedures,
including confidentiality, safeguarding, lone working, information governance,
equality, diversity and inclusion training and health and safety.
Miscellaneous
Establish strong working relationships with GPs and
practice teams and hub teams and work collaboratively with other care
coordinators, social prescribing link workers and health and wellbeing coaches,
supporting each other, respecting each others views and meeting regularly as a
team;
Act as a champion for personalised care and shared
decision making within the PCN
Demonstrate a flexible attitude and be prepared to
carry out other duties as may be reasonably required from time to time within
the general character of the post or the level of responsibility of the role,
ensuring that work is delivered in a timely and effective manner
Identify opportunities and gaps in the service and
provide feedback to continually improve the service and contribute to service
planning
Contribute to the development of policies and plans
relating to equality, diversity and reduction of health inequalities
Work in accordance with the PCNs policies and
procedures
Duties may vary from time to time without changing
the general character of the post or the level of responsibility
Contribute to the wider aims and objectives of the
PCN to improve and support primary care.
To support in the delivery of the PCN Network DES,
enhanced services and other service requirements on behalf of the PCN
Job description
Job responsibilities
1. NHS Health Check Delivery
2. Administrative Follow-Up
3. Care Coordination & Hub
Support
4. Teamwork & Rota Commitment
5. Service Development &
Governance
Professional
development
Work within a clinical team point for advice and
support.
Undertake continual personal and professional
development, taking an active part in reviewing and developing the role and
responsibilities, and provide evidence of learning activity as required;
Adhere to organisational policies and procedures,
including confidentiality, safeguarding, lone working, information governance,
equality, diversity and inclusion training and health and safety.
Miscellaneous
Establish strong working relationships with GPs and
practice teams and hub teams and work collaboratively with other care
coordinators, social prescribing link workers and health and wellbeing coaches,
supporting each other, respecting each others views and meeting regularly as a
team;
Act as a champion for personalised care and shared
decision making within the PCN
Demonstrate a flexible attitude and be prepared to
carry out other duties as may be reasonably required from time to time within
the general character of the post or the level of responsibility of the role,
ensuring that work is delivered in a timely and effective manner
Identify opportunities and gaps in the service and
provide feedback to continually improve the service and contribute to service
planning
Contribute to the development of policies and plans
relating to equality, diversity and reduction of health inequalities
Work in accordance with the PCNs policies and
procedures
Duties may vary from time to time without changing
the general character of the post or the level of responsibility
Contribute to the wider aims and objectives of the
PCN to improve and support primary care.
To support in the delivery of the PCN Network DES,
enhanced services and other service requirements on behalf of the PCN
Person Specification
Qualifications
Essential
- NVQ Level 3 in Health and Social Care or Equivalent
- Care Certificate
- NHS Health Check delivery experience
- Experience of health coaching or motivational interviewing
- High level of written and verbal communication skills
- 5 GCSEs including English & Math
- Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook
- ECDL or equivalent
Experience
Essential
- KNOWLEDGE
- Knowledge and understanding of administrative elements surrounding personalised and support care planning.
- Understanding of, and commitment to, equality, diversity and inclusion.
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Knowledge of how the NHS works, including primary care and PCNs.
- Ability to recognise and work within limits of competence and seek advice when needed.
- Basic knowledge of long term conditions and the complexities involved - medical, physical, emotional and social.
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
- EXPERIENCE
- Experience of administrative and IT systems.
- Experience of working within multi- professional team environments.
- Experience of supporting people, their families and carers in a related role.
- Experience of data collection and using tools to measure the impact of service.
Communication and Other
Essential
- COMMUNICATION SKILLS
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
- OTHER
- Access to own transport.
- Ability to travel across the locality.
Person Specification
Qualifications
Essential
- NVQ Level 3 in Health and Social Care or Equivalent
- Care Certificate
- NHS Health Check delivery experience
- Experience of health coaching or motivational interviewing
- High level of written and verbal communication skills
- 5 GCSEs including English & Math
- Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook
- ECDL or equivalent
Experience
Essential
- KNOWLEDGE
- Knowledge and understanding of administrative elements surrounding personalised and support care planning.
- Understanding of, and commitment to, equality, diversity and inclusion.
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Knowledge of how the NHS works, including primary care and PCNs.
- Ability to recognise and work within limits of competence and seek advice when needed.
- Basic knowledge of long term conditions and the complexities involved - medical, physical, emotional and social.
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
- EXPERIENCE
- Experience of administrative and IT systems.
- Experience of working within multi- professional team environments.
- Experience of supporting people, their families and carers in a related role.
- Experience of data collection and using tools to measure the impact of service.
Communication and Other
Essential
- COMMUNICATION SKILLS
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
- OTHER
- Access to own transport.
- Ability to travel across the locality.
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.
