York Road PCN Care Coordinator Support Worker

Job description

Job responsibilities

KEY WORKING REALTIONSHIPS

• Patients, patients families and carers
• GPs, nurses and other practice staff
• PCN pharmacists, social prescribers, primary care mental health team and other PCN attached staff

• Clinicians, carers and staff
• Care homes managers, carers, clinicians

• Community nurses and other allied health professionals

DUTIES AND AREAS OF RESPONSIBILITY:

Work with the PCN to support the personal care requirements for an identified cohort of patients, using available decision support aids.

Support the PCN in bringing together all a patients 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 patient.

Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system

Support the practices in identifying appropriate patient cohorts for targeted intervention

Update care plan templates on patients records, using correct read codes

Attend multidisciplinary meetings across local care organisations indentifying patients in need of review and collating any information required to facilitate their review prior to the meeting. Take minutes and coordinate.

Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations

Undertake delegated clinical procedures within own skills and competence when required (depending on experience and qualifications). Supporting with

Assist patients and carers in managing their own needs, answering their queries and supporting them to address their needs

Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care

Raise awareness of shared decision making and decision support tools, and assist patients to be more prepared for shared decision making conversations

To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN

Work in partnership with key providers in the local community to enable improved access to services for patients

Explore and assist patients to access personal health budgets where appropriate

Support patients 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

Actively engage with, assist, and provide advice to carers, to enable them to sustain their caring role escalating any concerns to the practice when required

Work with practices to support delivery of any national and local targets with regard to the GP contract e.g. PCN DES

Safeguarding

Identifies and takes appropriate safeguarding action when required in line with local policies

Support the practices in safeguarding processes, knowing when to intervene. Ensuring patients are protected from harm, while protecting their human rights.

Alert your line manager of any significant changes or events which relate to safeguarding

Support safeguarding investigations where required

Community and Partnership Working

Build effective relationships across the PCN and multidisciplinary team to embed the care coordinator role

Work in partnership with local providers and community groups to improve collaboration, co-ordination of care and support to the local population

Information and Confidentiality

Produce and present patient information to relevant groups and meetings to support patient care

To update patients records concisely and accurately with relevant information using the practice clinical system

To maintain strict confidentiality at all times in line with local policies

To identify specific patient cohorts from a variety of data sources to prioritise and coordinate their care needs.

Develop and audit caseloads to monitor outcomes against key performance indicators

General

To undertake all mandatory training required for the role and the PCN induction programme

To develop yourself and actively engage with and participate in training and service redesign activities

To attend a formal appraisal with your line manager at least every 12mths.

Contribute to the delivery of public health campaigns e.g. flu and cancer screening through advice or direct support

There is a requirement to be able to drive

To work at any location in the PCN and/or community in order to meet service needs

Perform any other duties as requested by the Primary Care Network as Direct Enhanced Service specifications develop

Interviews to be held on 7th or 10th August

Person Specification

Qualifications

Essential

• GCSEs/Diploma/HNC level (or relevant experience

Desirable

• NVQ Level 3 in a health or social care related discipline (or relevant experience)
• Care Certificate
• ECDL or other equivalent IT qualification

Experience

Essential

• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Signposting to patient services
• Administrative duties including preparing for meetings and writing minutes
• Working in partnership with other organisations to improve outcomes
• Working in a changing environments with high demand
• Completing audits and writing reports
• Multidisciplinary team working including health, social and 3rd sector organisations
• Microsoft Word/ Excel/ PowerPoint/ Teams applications

Desirable

• Experience in phlebotomy, general observations, wound care, health checks
• Understands about primary care and community services
• Using clinical systems and other digital software
• Working with patients/service users in a face-to-face role in the delivery of personal services

Skills and knowledge

Essential

• General Data Protection Regulations and Confidentiality
• Effective verbal, written and digital communication skills
• Health inequalities and wider determinants of health
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Understanding of medical terminology around frailty, population health management and long term conditions
• Ability to use own initiative and prioritises own workload without direct supervision
• Collecting and analysing patient data sets / reports to identify patient cohorts to prioritise
• Willing to develop and undertake training as required

Desirable

• Understanding of the current issues facing the NHS including Primary Care Networks

Other

Essential

• Right to work in the UK
• Car owner and has valid UK driving licence to travel across the PCN area and attend city wide meetings
• Professional attitude and appearance
• Reliability and ability to adapt to a changing environment including remote working when required
• Flexibility to develop the role as care coordinator to meet the needs of the PCN Service Specifications

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

South and East Leeds GP Group

Address

1st Floor Park Edge Practice

Asket Drive

Leeds

West Yorkshire

LS14 1HX

Employer's website

https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)