Care Coordinator

Care Coordinator

Job Title

PCN Care Coordinator - Care Homes

Location

Retford and Villages Primary Care Network, working alongside multiple sites.

Reporting To

Primary Care Network Manager

Key Relationships

Clinical Director and Executive Managers, all 5 member practices and staff, operational managers, multi-disciplinary teams, third party members and patients

Hours

30 - 37.5 per week

Pay Scale

£23,249 - £25,582 (pro rata)

Training Requirements

Training requirements and expectations will be set out by The Personalised Care Institute

Staff Management

This post has no staff management responsibilities, however, post holders may be asked to participate and support the induction and training of new members of staff within the multi-disciplinary team (MDT).

Overview of Retford and Village

Retford and Villages Primary Care Network is made up of 5 member practices and serves approximately 52,000 patients. The network is headed by a PCN Manager, Clinical Director, has an Executive Management team and includes voluntary and community sector organisations.

Purpose of the Roles

You will be working alongside two other Care Coordinators, working within the Personalised Care Team. A key part of the role is to support care home residents and care staff with a Personalised Care and Support Plan for all residents which will involve liaising closely with GPs, Practice staff, community nursing staff and other NHS professionals, acting as part of a wider multiagency integrated team.

**Key Working Relationships**

The post holder will be required to maintain constructive relationships with a broad range of internal and external stakeholders within and beyond the organisation. Key relationships will include:

- Personalised Care Team
- Wider PCN Team
- Care Home Steff
- Residents and relatives of care home residents
- GP’s and GP practice staff
- Community Specialist Practitioners
- Community Nursing Staff
- Secondary care discharge teams

**Key Care Home Responsibilities**
- To liaise with care home managers to identify those residents who would benefit from having a review.
- To organize regular meetings of Multi-disciplinary teams (MDT’s) supporting each care home and the EHICH clinical team.
- To ensure all residents receive a comprehensive geriatric assessment
- To ensure personalised care and support plans are completed for each resident including personal, health, social or wellbeing goals.
- To foster good communication between care home managers and all members of the MDT
- To maintain and develop engagement with GP’s, practice staff and community care staff.
- To liaise with multi agencies to coordinate pathways of care for residents
- To help residents manage their needs, answering their queries and supporting them to access primary care services
- To ensure residents have good quality information to enable them to make choices about their care
- To collect data on residents for recognised outcome measures. Ensure residents notes and care plans are updated to reflect any changes

General Duties / Key Responsibilities
- Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids
- Bring together all of a person’s identified care and support needs and explore their options to meet these into a single personalised care and support plan (PCSP), in line with best practice.
- Help people to manage their needs, answering their queries and supporting them to make appointments
- Support people to take up training and employment and to access appropriate benefits where eligible
- Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision-making conversation
- Ensure that people have good quality information to help them make choices about their care
- Support people to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing, including through 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
- 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, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles
- Support the coordination and delivery of MDTs withing PCNs.

Person Specification

Job Titles - PCN Care Coordinator

**KNOWLEDGE**

A good understanding of General Practice and MDT working

**SKILLS AND ABILITIES**

Good Planner

Positive outlook

Embrace challenge and change

Be able to think clearly and analytically

Excellent interpersonal and communication skills

Self-motivated

Results orientated

Be able to gather unbiased information

Reporting