Primary Care, Care Co-ordinator

1 week ago

Liverpool, Liverpool, United Kingdom Anfield and Everton Primary Care Network Full time

ANFIELD AND EVERTON PRIMARY CARE NETWORK (PCN)

PCN Care Coordinator Job Description

Job Title
PCN Care Coordinator

Line Manager
ARRS Lead

Accountable to
Anfield and Everton PCN

Hours per week
37

Job Summary
Care Coordination enriches the skill mix of primary care teams.

Care coordinators will play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with multiple long-term physical and mental health conditions, to provide coordination and navigation of care and support across health and care services.


They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.


This is achieved by bringing together all the information about a person's identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.


Main Responsibilities
The following are the core responsibilities of the PCN Care Coordinator:

  • 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
  • Assist people to access selfmanagement education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health
  • Support people to take up training and employment, and to access appropriate benefits where eligible, for example, through referral to social prescribers
  • Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joinedup service and the most appropriate support
  • Liaise with care homes, community matrons, district nurses and other members of community teams when needed
  • Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with longterm health conditions, and where appropriate, refer to other health professionals within the PCN
  • Support people to develop and implement personalised care and support plans
  • Review and update personalised care and support plans at regular intervals
  • Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes
  • Support the PCN in developing communication channels between GPs, people and their families and carers and other agencies
  • Conduct followups on communications from out of hospital and inpatient services
  • Support the coordination of multidisciplinary teams and delivery of clinical projects and services across the PCN
  • Identify unpaid carers and help them access services to support them
  • Maintain records of referrals and interventions to enable monitoring and evaluation of the service
  • Support practices to keep care records up to date by identifying and updating missing or outofdate information
  • Arrange, set agendas, minute, attend and contribute to internal and/or external meetings relevant to the post as delegated by the PCN
  • Assist seniors with HR processes, including but not limited to recruitment, induction, and absence management
  • Coordinate educational events requested by the PCN


There may be on occasion, a requirement to carry out additional tasks; this will be dependent upon factors such as workload, staffing levels and the strategic objectives of the network.


Generic Responsibilities
All staff at Anfield and Everton have a duty to conform to the following:

Equality, Diversity & Inclusion (ED&I)
A good attitude and positive action towards ED&I creates and environment where all individuals can achieve their full potential.

Creating such an environment is important for three reasons:
it improves operational effectiveness, it is morally the right thing to do, and it is required by law.

Safety, Health, Environment and Fire (SHEF)
This PCN is committed to supporting and promoting opportunities for staff to maintain their health, well-being and safety.

You have a duty to take reasonable care of health and safety at work for you, your team and others, and to cooperate with employers to ensure compliance with health and safety requirements.

All personnel are to comply with the Health and Safety at Work Act 1974, Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulati

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