Care Coordinator

Employer: Branch End Surgery

Overall Job Purpose

A vacancy has arisen for a Care Coordinator to join our mature Primary Care Network serving the populations in Branch End Surgery.

REPORTS TO: Practice Manager/PCN Lead Care Coordinators/ PCN Manager

The opportunity is to be part of a developing team, playing an important role within the PCN to proactively identify and work with people, including the care home patients, patients with cancer, and other long-term conditions (eg Dementia, frailty, Diabetes), to provide coordination and navigation of care and support across health and care services.

You will 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 will be 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.

Care coordinators review patients’ needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, and other professionals where appropriate.

The aim is to help people improve their quality of life and improve their experience across the health and care system.

They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and

learn as part of a team and committed to providing people, their families and carers with high quality support. This role is intended to become an integral part of the PCN’s multidisciplinary team, working alongside social prescribing link workers to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN. There may be a need to work remotely depending on the requirements of the role.

Please note that the role of a care coordinator is not a clinical role.

The roles that our PCN Care Coordinators will perform will vary between practices. They will depend on the needs of the GP practice that you will be attached to, as well as the PCN-led requirements. The lists of tasks and responsibilities are not restrictive or binding and are likely to develop over time.

Key responsibilities - [depending on practice requirements]

GENERIC - all Care Coordinators
- Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, ARRS staff and other primary care roles.
- Undertake accredited training as set out by The Personalised Care Institute
- Bring 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.
- To work closely with GPs and other primary care professionals 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;
- Manage reporting required and associated within the Direct Enhanced Service specifications and IIF targets for required services
- Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function;
- Attend regular meetings as appropriate with Lead Care Coordinators and PCN Management Team.

Other Care Coordination areas as required by the Practice
- This may include supporting patients with Frailty or other long term conditions (ie Diabetes, Dementia)

CANCER CARE - all care coordinators - Supporting and developing co-ordination and management of the Early Detection & Prevention of Cancer across the Primary Care Network and ensuring that the early part of the patient’s journey is as seamless as possible. The role may include (and will differ per practice):

- Identifying at risk populations using practice searches
- Support/ lead on signposting and advertising preventative advice
- Following up all 2 week wait referrals and ensure appointments made/attended, talk through processes
- Work with the PCN Cancer Operational Group and the Lead PCN Cancer Care Coordinator to audit safety netting procedures, support development of service and ensure DES/IIF requirements are fulfilled.
- Help patients navigate systems at a stressful time

Work with people, their families and carers to improve their understanding of the patients’ condition and support them to develop and review personalised care and support plans to manage

their needs and achieve better healthcare outcomes.
- Prepare patients for cancer care r