Primary Care Care Co-ordinator

5 months ago

Portsmouth, United Kingdom Island City Network PCN Full time

The following are the core responsibilities of the care coordinator. There may be, on occasion, a requirement to carry out other tasks; this will be dependent on factors such as workload and staffing levels: Process and effectively signpost patients to the appropriate healthcare professional depending on the presenting condition. Answering incoming phone calls, transferring calls, or dealing with the callers requests appropriately. Enter read-code data on SystmOne.

Manage all queries as necessary in an efficient manner. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach, and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views, and meeting regularly as a team. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning.

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. Support patients to utilise decision aids in preparation for a shared decision-making conversation. Holistically bring together all a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. 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.

Support people to take up training and employment and to access appropriate benefits where eligible. Support PCN staff and patients to understand their level of knowledge, skills, and confidence (there Activation level) when engaging with their health and wellbeing, including using the Patient Activation Measure. Assist people to access self-management education courses, peer support or intervention that support them in their health and wellbeing and increase their activation level. 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, working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals. Support the coordination and delivery of MDTs within the PCN. Secondary requirements: Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required as appropriate, refer to other health professionals within the PCN. Raise awareness within the PCN of shared decision making and decision support tools.

Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.

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