Job responsibilities
Job Description
Job Title:PCN Care Coordinator
Level:4
Job Family:Community Liaison
Hours:37.5 (full-time)
Employment Type:Permanent
Accountable and Responsible to:Practice Manager
1.1 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, which 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.
Working closely with the Social Prescribing Link Worker, Health and Wellbeing Coaches and other key members of the MDT to build trusting relationships with the GP surgeries within their PCN, creating coordinated patient care, enabling the individual to receive timely access to facilities.
Training and professional support will be provided for the job holder, building on existing skills and experience, through continuous development and utilising a professional development plan, as set out by the job holder and their appraiser.
1.2 Key Working Relationships
Key relationships include but are not limited to:
- Patients, service users and their representatives,
- PCN Clinical Directors, Commissioners and Local Partners,
- MDTs
- Hospital staff
- GP practice staff Locality Managers within the PCN,
- Key stakeholders in voluntary sector organisations,
- Overall PCN and GP practice workforce
1.3 Key Responsibilities
Clinical and Patient Client Care
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, based on what matters to the person.
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.
Work as an effective member of a multi-professional team, giving support to non-registered staff as required, without assuming supervision, education or line management role.
Complete documentation (including electronic patient records where used) as per PCN guidelines and Information Governance (IG) requirements, e.g. Data Protection.
Support the production and implementation of new working processes within the practice to optimise the quality of prescribing and patient care.
To support the overall effectiveness of exemplary coordination and delivery of the MDTs within the PCN.
Financial & Resources
Make appropriate use of equipment, technology (including software) which you are trained on, producing reports and other documentation as required, utilising the population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
Actively work toward developing and maintaining effective working relationships both within and outside the PCN.
Foster and maintain strong links with all services across the PCN and neighbouring networks.
Support collaborative working and take opportunities to initiate and sustain key working relationships with stakeholders as needed for the collective benefit of patients, both within PCN and with external networks across Bexley.
To have full knowledge of budgets, financial procedures, ensuring senior and peer colleagues are aware of the cost implications of any areas of non-compliance.
Manage resources required for key duties within the scope of the role, ensuring value for money at all times and maintain budget management responsibility allocated to the job holder in line with the scheme of delegation, develop, where required, cost-benefit analysis for spending and initiatives.
Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level, exploring and assisting people to access personal health budgets where appropriate.
Research & Development
Support the production of patient information leaflets and posters, providing advice and recommendations for projects and business change initiatives where appropriate, and ensuring that people have good quality written or verbal information to help them make choices about their care.
Supports public health campaigns, providing specialist knowledge on public health programmes available to the general public.
Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure.
Participate in continuing professional development, education, and training to keep up to date with evidence based knowledge and competence in all aspects of the role, for Continuing Professional Development (CPD) and a Personal Development Plan (PDP).
Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
Explore the potential for collaborative working and take opportunities to initiate and sustain key working relationships with stakeholders as needed for the collective benefit of patients.
Contribute to, and actively demonstrate the BHNC and PCN visions, aims and business objectives.
Policy & Service Development
Adhere to information governance policy requirements within the PCN.
Provides information to support the completion of audits where required.
Proactively provide feedback to you manager when patient care and service provision is impacted by changes to the PCNs policies, either negative or positive, to support the continual development of the PCN.
Feedback to your manager (or appropriate policy/service Lead) if you see a need or area of development within policies or service provision while carrying out your role.
Support the PCN management team in reviewing and developing organisational and Practice policies to ensure compliance, advising where improvements can be made.
Contribute to newsletters or bulletins where required, offering insights to the care coordinator role and activities.
Participate in multi-disciplinary protocol development as appropriate.
Support, contribute to and participate in internal and external organisational inspections.
Professional & Organisational Standards
Maintain confidentiality at all times.
Represent the organisation positively and professionally, behaving as an ambassador for the PCN by displaying the organisations values and levels of expected professionalism at all times.
Take responsibility for supporting own development (particularly in relation to the training as set out in the Personalised Care Institute), learning and performance including participating in non-clinical supervision and acting as a positive role model for others.
Work within policies regarding family violence, vulnerable children and adults, substance abuse and addictive behaviour, and makes referrals as appropriate for safeguarding.
Actively support the implementation of national strategies and policies into local implementation strategies that are aligned to the values and culture of general practice, promoting them throughout the PCN.
Adheres to and proactively promotes Infection Control standards and complies with Health & Safety, Corporate, Clinical and Information Governance.
Have an awareness of cohorts of patients at high risk, which may include risks that are patient related, medicine related, or both, and know how to mitigate and reduce risks accordingly.
Set up and manage systems to ensure continuity of services to patients.
