Pcn Care Coordinator

9 months ago

Hillingdon, United Kingdom The Confederation, Hillingdon CIC Full time

**About Us**:
The Confederation, Hillingdon CIC works with general practice and other healthcare providers in Hillingdon to deliver high quality clinical services to patients. Our aim is to improve care for patients by working collaboratively across primary care and our partners as part of the Integrated Care Partnership. The Confederation team also work to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We are of the NHS but independent, innovative and transformational.

General capacity across primary care is being expanded rapidly. The Confederation is determined to develop as an attractive place to work that provides rewarding roles and opportunities to grow in order to attract and retain great staff that in turn provides the highest quality care.

**Our Values**:
**Job Summary**:
An exciting opportunity has arisen within Primary Care to work as a Care Coordinator at The Confederation, Hillingdon CIC.

Care Coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term 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 people 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 persons 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 could provide time, capacity and expertise to support people in preparing for, or following-up, clinical conversations. Enabling them to be more actively involved in managing their care and supporting them to make choices that are right for them. Care Coordinators help people improve their quality of life.

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 PCNs multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

Please note that the Care Coordinator works under delegation of a registered health professional.

**Primary Responsibilities**:
The role will be to work within our network of GP Practices to provide a central coordination role for patient care planning as well as:

- Work with people, their families and carers, to improve their understanding of their condition.
- Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
- Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
- Assist people to access self-management 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.
- Provide coordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.
- Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
- Support the coordination and delivery of multidisciplinary teams with the PCN.
- Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations.

**Key Tasks**:
**Enable Access to Personalised Care and Support**:

- Take referrals or proactively identify people who could benefit from support through care coordination.
- Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
- Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance.
- Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them.
- Use tools to measure peoples levels of knowledge, skills and confidence in mana

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