Job responsibilities
The Population Health Management Hub will also be central to developing solutions to unplanned care by understanding what factors are driving poor outcomes in different population groups. Ensuring the PCN are designing and planning models of care which will improve health and wellbeing today and also in the future.
This will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population.
The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions, SMI and Obesity . An ethos of promotion of independence and partnership-working is integral to this post.
Primary Duties and Areas of Responsibility
Care Coordinator Hub
- Support patients and practices in appointment bookings for target groups of patients.
- Supporting patients to complete questionnaires to identify and assess their levels of wellbeing and skills, knowledge to manage their own health.
- Liaise with all clinical and non-clinical members in the multi-disciplinary team (MDT).
- Support management and allocation of referrals into the personalised care team.
- Support reporting requirements associated within the DES specifications for required services.
- Support reporting to strategic team any systematic trends of potential threats and their implications or opportunities and likely future developments.
- Manage and support PCN clinical system hub unit, rotas and smart card access.
- Answer and take calls from internal PCN staff and external MDT members about patients receiving care from the personalised care team and other PCN MDT staff as appropriate.
- Performing administrative tasks (including appointments, diaries, patient searches).
Patient Identification
Receive and collate information from clinical systems to understand what factors are driving poor outcomes in different population groups.
- Use search tools for risk stratification of patients.
- Review end of year QoF data for the PCN.
Maintenance of IT based information systems and responsibility for key performance data:
- To ensure the IT requirements for recording activity are adhered to in collaboration with other team members
- Accurate update and maintenance of GP systems within the MDT.
- To provide agreed performance/activity data within the MDT and PCN and wider BHR PCN.
Communication and collaborative working relationships
- Demonstrates ability to work as a member of a team.
- Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary.
- Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.
- Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations.
- Work with patients, PCN practices and partners.
- Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT.
- Meet regularly with the service lead and review prioritisations.
- Keep the MDT and BHR PCN abreast of good news stories.
- Manage and prioritise workload on a daily basis and deal with the competing demands.
Other responsibilities
- To act at all times in an anti-discriminatory manner.
- To be able to plan and respond to workload according to operational priorities.
- To support the delivery of these functions across wider locality areas where necessary.
- To undertake any training required in order to maintain competency including mandatory training.
- To contribute to, and work within a safe working environment.
- The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures.
- The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.
- The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.
Patient Care
- Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding.
- Effectively use all methods of communication and be aware of and manage barriers to communication.
- Effectively recognise and manage challenging behaviours, carers and or relatives.
- Provide information to patients, their carers and/or relatives on behalf of the team.
Supporting Care Delivery
- Be the point of liaison for patients and interface with all health and social care professionals, including keeping everyone informed and updated.
- Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.
- Follow through with patients and others involved to ensure all services and care arrangements are in place.
Autonomy/Scope within Role
The post holder will be required to work within clearly defined organisational protocols, policies and procedures.
Key Relationships Key Working Relationships Internal:
- Service Lead for the PHMH.
- GPs and General practice teams within the PCN.
- PCN Clinical Director/s.
- PCN network manager.
- MDT members including but not exhaustive: Clinical Pharmacists, technicians, Physician Associates, Physios, Paramedics, Social Prescribing Link Workers, Patient Ambassadors, health and wellbeing coach, practice managers.
Key Working Relationships External:
GPs from neighbouring PCNs
Service providers
Social care
Voluntary services
Patients/service users
Carers/relatives
Health and Safety/Risk Management
- The post-holder must comply at all times with the organisation and Practices Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System.
- The post-holder will comply with the Data Protection Act (1984), The General Data Protection Regulations (2018) and the Access to Health Records Act (1990).
- The post-holder will comply with all necessary training requirements relevant to the role as identified by the organisation.
Equality and Diversity
The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc.
Respect for Patient Confidentiality
The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.
Special Working Conditions
The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies.
Job Description Agreement
This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.
