Job responsibilities
The post holder will work collaboratively with a multidisciplinary health & social care team to support and provide holistic treatment and care for our diverse population groups. Tackling health inequalities are core focuses for the PCN, and we are looking for a candidate that will be able to work with supporting the needs of vulnerable patients this job will be particularly focused on our homeless population. The City of London, which sits within the PCN has a much higher rough sleeper count than Hackney, and often these groups of people are vulnerable and neglected.
Working closely with GPs and other primary care professionals within the PCN, you will identify and manage a caseload of identified patients, making sure that appropriate support is made available to them, whilst ensuring that their changing needs are addressed.
Knowledge and expertise of the factors that increase risk of homelessness, and signs of vulnerability is ideal, alongside a good and current knowledge of the national and local developments regarding housing, homelessness and no recourse to public funds, and the likely impact of these.
You will be working closely with housing associations, local homelessness charities and organisations and other relevant social care organisations, in support of the patients care and wellbeing.
You will focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities and population health management risk stratification. As a care coordinator, you will provide expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. You will be the point of liaison for patients and interface with all health and social care professionals, including keeping everyone informed and updated. The post holder will work as part of a multi- disciplinary team in a patient-facing role.
The postholder will work with a diverse range of people from different cultural and social backgrounds. The ability to work confidently and effectively in a varied, and sometimes challenging environment is essential.
The successful candidate will have excellent interpersonal and communication skills, and be organised, patient and empathetic. They will have experience of working in health, social care or other support roles including direct contact with people, families or carers.
The ability to work confidently and effectively in a varied, and sometimes challenging environment is essential. Specific training will be provided where required.
The Care Coordinator responsibilities include but are not limited to the following:
- To work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients
- In collaboration with clinicians, administrative and reception team colleagues, to help patients with complex needs navigate the health and care system. This includes helping them 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.
- Support patients to utilise decision aids, help create single personalised care and support plans, in line with best practice.
- 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.
- 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 (PAM)
- Provide coordination and navigation for people and their carers across health and care services, including the use of digital tools.
- Support people to take up training and employment, and to access appropriate benefits where eligible;
- 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
- Explore and assist people to access personal health budgets, where appropriate.
Work closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Other key relationships include: City and Hackney Neighbourhood team, GP Confederation, social care, secondary care (Homerton and ELFT), community services, community and Clinical Pharmacists, City and Hackney CCG, Hackney Community and Voluntary sector and fellow care coordinators.
Support the Clinical directors in the delivery of the DES specifications.
Support practices in engaging patients in initiatives such as cancer screening, LTC checks, vaccination & immunisation uptake.
Engage, attend and link in with the PCN community navigation team and the wider neighbourhood MDT meetings.
