PCN Care Coordinator - Care Home & Frailty Team

Job description

Job responsibilities

Job Description:

Job Description and Personal Specification

Job Title:Care Coordinator

Reports to:PCN Operational Manager & Care Home and Frailty Team Lead.

Job Summary

• The Care Coordinator will work as a key part of the Primary Care Network (PCN) multi-disciplinary (MDT) team.
• Works closely with the GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
• Plays an integral role in facilitating the care home MDT, to improve the continuity of care by acting as a point of contact for residents, families and professionals.
• Contributes to tackling inequalities in health and social care. An ethos of promotion of independence, shared decision making, personalisation and partnership working is integral to this post. As the role evolves the care coordinator will undertake direct work with patients and families to develop personalised care plans.
• This role can be a hybrid role with a maximum of 2 days WFH per week ( For full time staff)

Core Hours

Full time, 37.5 hours per week.

Key Responsibilities

• Provide a first point of contact for patients and clinicians in coordinating patients care.
• Deal with incoming queries from patients and/or their carers and other healthcare providers.
• Encourage people, their families and carers to provide feedback and engage fully in the care coordination process.
• Ensure timely follow up and action for patients from communications from community and secondary care.
• Monitor tasks to ensure they are completed and care delivered through regular audit of the clinical system.
• Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers and other primary care professionals.
• Signpost and organise appointments, follow ups or other actions to help the PCN provide high quality, compassionate care to our patient population.
• Support the alignment of care homes to practices, including new patient registrations.
• Support the care home MDT with the weekly ward rounds through identification of people in need of review, collation of information on patients requiring MDT input. Also to provide coordination and administrative support to the MDT.
• Support the PCN in coordinating all key activities including access to services, advice and information, and ensuring health and care planning is timely, efficient and patient-centred.
• Support PCN staff and patients to be prepared to have shared-decision making conversations, including utilising decision aids and tools.
• Work collaboratively with other Care Coordinators across the PCN to share best practice.
• Work sensitively with patients, their families and carers to capture key information, enabling comprehensive and accurate records of support.
• Work with the PCN MDT to utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.

The list of duties in the job description should not be regarded as exclusive or exhaustive. There will be other duties and requirements associated with the job and the right to update the job description from time to time to reflect changes in or to the job.

Job Types: Full-time, Part-time, Permanent

Benefits:

• Company pension
• On-site parking
• Work from home - up to 2 days per week

Work Location: Hybrid remote in Brighton BN1 5AZ

Person Specification

Skills/Knowledge/Experience

Essential

• Minimum of 1 year of experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
• Able to prioritise and manage own workload
• Able to work as part of a team
• Excellent interpersonal skills
• Excellent organisational and administration skills
• Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes
• Experience handling confidential/sensitive information
• Experience of providing advice/signposting to service users
• Knowledge of Microsoft Office suite

Desirable

• NVQ 3 or equivalent and/or relevant basic/first level professional qualification
• Experience of co production with patients or service-users
• Experience of using technology and digital tools to support health and well being
• Knowledge of Information Governance and data quality
• Knowledge of medical patient systems
• Understanding of health and social care processes

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

Preston Park Community PCN Limited Company

Address

Deneway Surgery

Ground Floor Lions Dene, 11 The Deneway

Brighton

East Sussex

BN1 5AZ

Employer's website

https://prestonparkcommunitypcn.gpweb.org.uk/ (Opens in a new tab)