PCN Care coordinator

Job description

Job responsibilities

This role is for 15 hours per week. One shift will need to cover a Friday PM for practice cover. The remaining hours are negotiable.

Care Coordinators have the following key responsibilities, in delivering health services:

a. utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care;

b. support patients to utilise decision aids in preparation for a shared decision-making conversation;

c. holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person;

d. help people to manage their needs through 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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health;

e. support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers;

f. assist people to access self-management education courses, peer support or interventions that support them to take more control of their health and wellbeing;

g. explore and assist people to access personal health budgets where appropriate;

h. provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; and

i. support the coordination and delivery of MDTs within the PCN.

j. Using clinical system searches to proactively identify patients who are due a review of their long term condition (asthma / COPD / diabetes / NDH / learning disabilities / dementia)

k. Assisting with processing Online Consultation appointment requests

l. Assisting the GPA with processing blood pressure results received by patients

The following sets out the key wider responsibilities of Care Coordinators:

a. work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN;

b. raise awareness within the PCN of shared decision-making and decision support tools; and

c. 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.

Confidentiality:

• In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information about their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately

• In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff, and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential

• Information relating to patients, carers, colleagues, other healthcare workers, or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data

Health & Safety:

The post-holder will assist in promoting and maintaining their own and others health, safety, and security as defined in the practice Health & Safety Policy, the practice Health & Safety Manual, and the practice Infection Control policy and published procedures. This will include:

• Using personal security systems within the workplace according to practice guidelines

• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks

• Making effective use of training to update knowledge and skills

• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards

• Actively reporting of health and safety hazards and infection hazards immediately when recognised

• Keeping own work areas and general/patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holders role

• Undertaking periodic infection control training (minimum annually)

• Reporting potential risks identified

• Demonstrate due regard for safeguarding and promoting the welfare of children.

Equality and Diversity:

The post-holder will support the equality, diversity, and rights of patients, carers, and colleagues, to include:

• Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation

• Respecting the privacy, dignity, needs, and beliefs of patients, carers, and colleagues

• Behaving in a manner that is welcoming to and of the individual, is non-judgmental, and respects their circumstances, feelings priorities, and rights.

Personal/Professional Development:

The post-holder will participate in any training program implemented by the PCN/practice as part of this employment, such training to include:

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development

• Taking responsibility for own development, learning, and performance and demonstrating skills and activities to others who are undertaking similar work

Quality:

The post-holder will strive to maintain quality within the practice, and will:

• Alert other team members to issues of quality and risk

• Assess own performance and take accountability for own actions, either directly or under supervision

• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance

• Work effectively with individuals in other agencies to meet patients needs

• Effectively manage own time, workload, and resources

Communication:

The post-holder should recognize the importance of effective communication within the team and will strive to:

• Communicate effectively with other team members

• Communicate effectively with patients and carers

• Recognize peoples needs for alternative methods of communication and respond accordingly

Contribution to the Implementation of Services:

The post-holder will:

• Apply practice PCN/policies, standards, and guidance

• Discuss with other members of the team how the policies, standards, and guidelines will affect own work

• Participate in audit where appropriate

Person Specification

Experience

Desirable

• Emis experience
• Primary care experience

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

Fareham & Portchester PCN

Address

Gudge Heath Lane Surgery

187 Gudge Heath Lane

Fareham

Hampshire

PO15 6QA

Employer's website

https://farehamandportchesterpcn.gpweb.org.uk/our-primary-care-network (Opens in a new tab)