Pcn Care Coordinator

2 weeks ago


London, United Kingdom South Fulham PCN Co. Full time

**Job summary**

The PCN Care Coordinator has the unique opportunity to work for South Fulham PCNCo. for the seven practices that comprise the South Fulham Primary Care Network (PCN). The post will support the delivery of personalised and coordinated care of patients. South Fulham PCN has a list size of 61,000 registered patients.

The PCN Care Coordinator will provide extra time, capacity and expertise to support patients in preparing for clinical conversations or in following up discussions with primary care professionals. You will work closely with GPs and other primary care colleagues within the primary care network (PCN) to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers (if appropriate), and ensuring that their changing needs are addressed. Care coordinators will focus on the delivery of personalised care to reflect individual patient needs, local PCN priorities, health inequalities and at risk groups of patients.

**Main duties of the job**

The main role of the successful applicant will be to proactively communicate and coordinate information between patients, their carers, doctors and professionals and to assist the clinical teams with administrative functions within the practice.

Post holder will holistically bring together all of a person’s 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.

Post holder will also 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

The successful applicant will work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN

**Main duties & responsibilities**:
The main role of the successful applicant will be to proactively communicate and coordinate information between patients, their carers, doctors and professionals and to assist the clinical teams with administrative functions within the practice.
- 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 of a person’s 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
- Assist people to access self-management education courses, peer support or interventions that support them to take more control of 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, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals
- Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN
- Raise awareness within the PCN of shared decision-making and decision support tools

**Key tasks**
- Review people’s needs and help to connect them to the services and support they require, whether within the practice or elsewhere - for example, community and hospital-based services.
- Work with patients individually to develop a personalised care and support plan
- Build trusting relationships with patients to listen on what matters to them and with primary care colleagues
- Support people in preparing for or following up clinical conversations they have with healthcare professionals, to enable them to be actively involved in managing their care and supported to make choices that are right for them.
- Work closely with social prescribing link workers and health and wellbeing coaches, referring people to them and also receiving referrals in return.
- 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 using tools to understand peoples level of knowledge, confidence in skills in managing their own health;
- Support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers
- Support the coordination and delivery of MDTs (multi disciplinary teams) within the PCN

**Overview of your organisation**

South Fulham PCNCo. are the newly



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