Care Coordinator

Job summary

• Working as part of a Multi-Disciplinary Team (MDT), the job holder will play a key role in progressing the Primary Care Network (PCN) vision of creating a new wider Community Service, enhancing existing care models in a collaborative way across the PCNs within Bexley.
• This role plays a pivotal part in improving the quality of seamless coordinated care across the PCN, that enables MDTs to advance in their ways of working and ultimately contributes to the effectiveness of patient care provided.
• As a Care Coordinator the job holder will work closely with the practices and the MDT, as a pivotal role for ensuring all patients across the locality receive the best possible care and service. This role will support the Clinical Directors and other key stakeholders in coordinating all activity including access to services, advice and information, and ensuring health and care planning is timely, efficient and patient-centred.
• The job holder will assist in the advancing of digitalisation of systems and networks to enhance the flow and accessibility of data and information to ensure the seamless coordination of the patients journey through primary care

Main duties of the job

• To work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients.
• To support Clinical Directors and other key stakeholders in the successful delivery and implementation of the Directed Enhanced Service (DES).
• To work closely and in partnership with the Social Prescribing Link Workers and Health and Wellbeing Coaches, supporting patients to utilise decision aids, help create single personalised care and support plans, in line with best practice.
• To help patients manage their needs through proactively responding to queries, making and managing appointments, other interventions that progress the patients care journey, holistically bringing 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.
• Modify and adapt working practices to meet the needs of the patient, where appropriate, providing coordination and navigation through the aid of digital tools for patients and their carers across the health and care services.
• Complete documentation (including electronic patient records where used) as per PCN guidelines and Information Governance (IG) requirements, e.g. Data Protection.
• To support the overall effectiveness of exemplary coordination and delivery of the MDTs within the PCN.

About us

• Bexley Health Neighbourhood Care (BHNC) is a GP Federation supporting the 21 Bexley Practices / 4 PCNs who are working collaboratively to enhance the health and wellbeing of Bexley residents, covering over 246,000 patients.
• Organisational Values / Objectives
• The goals of BHNC are to work strategically with all Bexley Primary Care Networks (PCNs), to help secure the best services for patients whilst working together, to support the member practices in the challenges of a changing NHS.
• Bexley Health Neighbourhood Care (BHNC) aims to improve the morale of PCNs / general practice in Bexley, by sharing expertise, services and supporting its workforce. BHNC will make a positive impact on medical services in Bexley, by working closely with the CCG, local NHS trusts, local providers and patient groups, to improve the delivery of healthcare to the local population.