Care Co-ordinator

3 weeks ago


Winsford, United Kingdom High Street Medical Practice Full time

Winsford PCN Care Coordinator

RESPONSIBLE TO: Clinically: Winsford Clinical Director

Administratively: Lead Employer

HOURS: 37½ per week

LOCATION: Working across GP Practices in Winsford including Swanlow Medical Centre, Weaver Vale Surgery, Willow Wood Surgery, High Street Medical Practice and Launceston Close Surgery

FUNCTION

With the creation of the 2020/21 Network Direct Enhanced Service (DES) and the introduction of the NHS Additional Role Reimbursement scheme for new primary care roles, an opportunity has arisen for Primary Care Networks (PCNs) to bring in roles that support GP practices, Networks and elements of the Network DES and this role looks to support this work administratively, linking the PCN and practices with the wider health care community, including but not limited to MDTs, social care, community care, pharmacy teams and care homes.

The role is a mixture of administration and care coordination, supporting teams and practices in delivering the key performance indicators of the Network DES and other key network service areas.

**REQUIREMENTS OF THE ROLE**

You must undertake mandatory training as set out by the Personalised Care Institute

The Care Coordinator will work closely and in partnership with Social Prescribers, Health & Wellbeing Coaches, and the other, wider healthcare colleagues as mentioned above in the “Function” section of this document to ensure mutual patients’ needs are being met.

**PRINCIPAL ACCOUNTABILITIES**

**PCN Board Meetings**
- You will put together the agenda and take the minutes of the monthly PCN Board Meetings and ensuring they are disseminated in a timely fashion.

**Enhanced Health in Care Homes**
- You will act as a link between the PCN practices and the PCN CQC registered care homes.
- You will utilise population health intelligence to proactively identify a cohort of patients to allow health colleagues to deliver personalised care. This may take the form of risk stratification, clinical system searches and information from the CCG Business Intelligence teams.
- You will support administratively clinicians to utilise decision aids to prepare patients for shared decision-making conversations.
- You will support administratively clinicians to bring together a person’s identified care and support needs and ensure all patients have a Personalised Care and Support Plan, based on what matters to the person and ensure they are kept up to date with any changes and ensure there is a robust system in place for reviewing and updating them.
- You will ensure that clinicians have access to the tools they need to develop a Personalised Care and Support Plan and support administratively the creation of these for each patient.
- You will help patients and their carers to answer queries which allows them to navigate or signpost for their health needs and ensure they have excellent good quality written or verbal information. This may take the form of being the link between the practice, MDT or care home and the wider healthcare community, or signposting towards Social Prescribers or Health Coaches.
- You will coordinate the PCN GP and Care Home Managers meetings as and when needed, putting together the agenda, and taking the minutes at these meetings and ensuring they are disseminated in a timely fashion.
- You will ensure safeguarding issues or patient related concerns are raised appropriately to the appropriate individual.
- You will coordinate for practice teams the weekly PCN care home ward rounds where required, providing administratively support where needed.
- You will support the care home vaccination programmes throughout the PCN, acting as a liaison between patients, care homes, practices teams etc as appropriate.

**PCN Multi-Disciplinary Team Meetings**
- You will coordinate the PCN Community and Care Home Patients MDT, taking patient case referrals, ensuring the appropriate teams attend the meetings, putting together the agenda and taking the minutes at these meetings and ensuring they are disseminated in a timely fashion.

**Safeguarding Reports**
- You will collate the information for the iART Health Information Reports, the Initial and Review Child Protection Conference Reports and the MARAC Domestic Violence Reports for all PCN practices, getting the reports signed off as needed and returned to the relevant Safeguarding Hub within the given timeframe and update practice/patient records, as necessary.
- You will ensure all 5 member practices have the most up to date guidance on Safeguarding, including flow charts and contact details for reporting Safeguarding issues.

**Cancer Screening Reminders**
- You will send reminders to patients who have not responded to the invitations for routine bowel cancer screening.

**PCN IIF/QOF Targets**
- You will support the PCN to meet the IIF/QOF targets that you are able to influence through your role.

This Job Description is not exhaustive, and the roles and responsibilities may change over the coming



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