Job summary
Job Summary
Primary Care Networks have been established to bring together resources from a
range of different organisations to deliver holistic integrated health, social and
care support for their local population.
As a Care Coordinator you will work as a key part of the primary care network
(PCN) multidisciplinary team. You will be the key link to the people whose care
you are supporting, operating as a go to person to ensure that their care is
seamless, they are active decision makers in their own care, and that everyone
involved is working together. Care Coordinators provide extra time, capacity and
expertise to support patients in preparing for or in following up clinical
conversations they have with primary care professionals.
You will work closely with the GPs and other primary care professionals within
the PCN to identify and manage a caseload of identified patients, making sure
that appropriate support is made available to them and their carers, and ensuring
that their changing needs are addressed.
Using agreed templates and assessment tools you will ensure an outcome-based
care plan is co-produced with each person. You will review plans at regular
intervals to capture progress, ensure they remain appropriate for the individual
and identify any input required from wider team members including healthcare
specialists.
Main duties of the job
Primary Duties and Areas of Responsibility
Take overall responsibility for coordination and delivery of the weekly PCN
led MDT meetings. A key role of the Care Coordinator will be to schedule
the weekly MDT meetings, manage the meeting agenda items; ensuring
that all new referrals are identified, and information circulated to team
members in advance of the meeting.
Utilise population health intelligence and PCN / Partner data to proactively
identify and work with a cohort of patients to deliver personalised care.
Support patients to utilise decision aids in preparation for a shared
decision-making conversation.
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.
Help people 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 people to take up training and employment, and to access
appropriate benefits where eligible.
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.
About us
Newly formed Primary Care Network (PCN) linked to 4 GP Surgery sites, team is growing and evolving and now seeking more staff to deliver the care services to our patients.
Developing new and exciting additional roles to support GP's and clinical teams at enhancing patient services in the local community.
Vibrant, friendly working atmosphere with great career progression opportunities.
Job description
Job responsibilities
Take overall responsibility for coordination and delivery of the weekly PCN
led MDT meetings. A key role of the Care Coordinator will be to schedule
the weekly MDT meetings, manage the meeting agenda items; ensuring
that all new referrals are identified, and information circulated to team
members in advance of the meeting.
Utilise population health intelligence and PCN / Partner data to proactively
identify and work with a cohort of patients to deliver personalised care.
Support patients to utilise decision aids in preparation for a shared
decision-making conversation.
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.
Help people 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 people to take up training and employment, and to access
appropriate benefits where eligible.
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.
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.
Provide coordination and navigation for people and their carers across
health and care services, working closely with social prescribing link
workers, health and wellbeing coaches, and other primary care
professionals.
Work with the GPs and other primary care professionals within the PCN to
identify and manage a caseload of patients, and where required and as
appropriate, refer people back to other health professionals within the
PCN.
Raise awareness within the PCN of shared decision making and decision
support tools.
Raise awareness of how to identify patients who may benefit from shared
decision making and support PCN staff and patients to be more prepared
to have shared decision-making conversations.
Job description
Job responsibilities
Take overall responsibility for coordination and delivery of the weekly PCN
led MDT meetings. A key role of the Care Coordinator will be to schedule
the weekly MDT meetings, manage the meeting agenda items; ensuring
that all new referrals are identified, and information circulated to team
members in advance of the meeting.
Utilise population health intelligence and PCN / Partner data to proactively
identify and work with a cohort of patients to deliver personalised care.
Support patients to utilise decision aids in preparation for a shared
decision-making conversation.
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.
Help people 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 people to take up training and employment, and to access
appropriate benefits where eligible.
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.
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.
Provide coordination and navigation for people and their carers across
health and care services, working closely with social prescribing link
workers, health and wellbeing coaches, and other primary care
professionals.
Work with the GPs and other primary care professionals within the PCN to
identify and manage a caseload of patients, and where required and as
appropriate, refer people back to other health professionals within the
PCN.
Raise awareness within the PCN of shared decision making and decision
support tools.
Raise awareness of how to identify patients who may benefit from shared
decision making and support PCN staff and patients to be more prepared
to have shared decision-making conversations.
Person Specification
Qualifications
Essential
- GCSE or equivalent grade C level qualification in Maths and English.
- Experience Minimum of 1 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
- Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
- Experience providing advice/signposting to patients.
- Experience of undertaking quality improvement activity.
- Excellent organisational and administration skills.
- Ability to analyse and interpret information and present results in a clear and concise manner.
- Able to prioritise and manage own workload.
Desirable
- Experience of working in a multi-disciplinary setting where influence and negotiation is required.
- Experience of using technology and digital tools to support health and wellbeing.
- Experience of co-production with patients or service-users.
- Skills and Knowledge Excellent influencing and negotiating skills.
Experience
Essential
- Experience working within a healthcare setting and interacting with patients.
Person Specification
Qualifications
Essential
- GCSE or equivalent grade C level qualification in Maths and English.
- Experience Minimum of 1 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
- Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
- Experience providing advice/signposting to patients.
- Experience of undertaking quality improvement activity.
- Excellent organisational and administration skills.
- Ability to analyse and interpret information and present results in a clear and concise manner.
- Able to prioritise and manage own workload.
Desirable
- Experience of working in a multi-disciplinary setting where influence and negotiation is required.
- Experience of using technology and digital tools to support health and wellbeing.
- Experience of co-production with patients or service-users.
- Skills and Knowledge Excellent influencing and negotiating skills.
Experience
Essential
- Experience working within a healthcare setting and interacting with patients.
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.