Pcn Care Coordinator

2 weeks ago


Leeds, United Kingdom South & East Leeds GP Group Full time

**Care Coordinator**

**South and East Leeds GP Group**

**The closing date is 01 January 2023**

**Job summary**

This role will be hosted by South East Leeds GP Group, and will be based in the LS25 LS26 Primary Care Network (PCN).

LS25/26 PCN has a patient population of circa 75,000 across 7 practices:
Garforth Medical Centre

Gibson Lane Practice

Kippax Hall Surgery

Lofthouse Surgery

Moorfield House Surgery

Nova Scotia Medical Centre

Oulton Medical Centre

We are very excited to be recruiting another Care Coordinator to join our PCN team. We currently have 6 Care Coordinators and the rest of our PCN staff include pharmacists, pharmacy technicians, trainee pharmacist, paramedics, Health Care Assistant/Social prescribers (doing home visits and support for housebound patients), health and wellbeing coach, occupational therapists, physiotherapists, physician associates, admiral (dementia) nurse and nurse associate. We are in the process of recruiting 2 Social Prescriber / Link workers.

Please see our staffing structure, but note that it is always being updated as we continue to develop and grow our team.

**Main duties of the job**

Our Care Coordinators will play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They will be working closely with practice and PCN staff to identify, engage with and proactively coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, people living with severe mental illness or learning disabilities, and those with long-term health conditions.

As well as being linked with individual practices they will work together as a team with each Care Coordinator taking a lead for the PCN in a particular area e.g. mental health, learning disabilities, frailty and unpaid carers. This will include sharing learning and best practise both within the team and across the PCN.

Our Care Coordinators will support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings including monthly Care homes meetings.

To run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, and other services including self-management services. Support with patient engagement, which will include ensuring that information is accessible for all, and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.

**About us**

**Job description**

**Job responsibilities**

**KEY RESPONSIBILITIES**

Coordinate multidisciplinary meetings across local care organisations including identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.

Provide admin support to multidisciplinary meetings including taking minutes.

Utilise GP Practice clinical systems (SystmOne) and population health data to proactively identify relevant cohorts of patients to deliver personalised care

Support patients within these cohorts to access health checks and other health services

Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system

Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations

Assist patients and carers in managing their own needs, answering their queries and supporting them to address their needs

Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding

Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care

Raise awareness of shared decision making and decision support tools, and assist patients to be more prepared for shared decision making conversations

To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN

Work in partnership with key providers in the local community to enable improved access to services for patients

Actively engage with, assist and provide advice to carers, to enable them to sustain their caring role escalating any concerns to the practice when required

Work with practices to support delivery of any national and local targets with regard to the GP contract e.g. PCN DES and I&IF

Support the PCN in bringing together all of a patients 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 patient.

Explore and assist patients to acc


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