Pcn Care Co-ordinator

OWLS CIC - West Lancashire GP Federation is looking for a Care Co-ordinator to join.

An exciting opportunity has arisen for a Care Co-ordinator to develop a pioneering role within primary care. The role will provide co-ordination and navigation for people and their carers across health and care services.

Care Co-Ordinators provide extra time, capacity and expertise to support patients in preparing for or in following up clinical conversations that they have with primary care professionals i.e. doctors, nurses, physiotherapists, physician associates, paramedics etc. They provide co-ordination and navigation for people and their carers across in a variety of settings, including care homes where they will work with the Enhanced Care Home Scheme Team to proactively manage this cohort of patients.

The post holder will work closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. Their focus is on delivering a comprehensive model for personalised care, reflecting local priorities, health inequalities and population health management risk stratification. They also support the coordination and delivery of MDTs within PCNs.

Care Co-Ordinators will:

- Work closely with practice and PCN healthcare roles, the PCC is to identify and work with a cohort of people to support their personalised care requirements, using any available decision support tools such as Patient Activation Measure (PAM), templates and software
- Meet patients, patient carers and family members to discuss their personalised care requirements, the services available to them and the help they want
- Visit patients, checking on the care that they have received and documenting it accordingly
- Work with the care team to evaluate interventions and identify where and when further ones will be required
- Help people to manage their needs by answering their queries and supporting them in making appointments
- Support people to access appropriate benefits where eligible as well as taking up employment and training
- Assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools
- Provide patients with high quality, easy to understand information to assist them in making choices about their care
- Support patients in understanding their level of knowledge, skills and confidence (known as activation level) when participating in their health and well-being using, where appropriate, the PAM
- Liaise with other PCCs in other practices across the region and share best practice
- Assist patients to access self-management education courses, peer support or interventions that support them in their health and well-being
- Where appropriate, to assist patients to access personal health budgets
- Provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW)
- Support in the delivery of enhanced services and other service requirements on behalf of the PCN
- Lead in the management of patient complaints and participate in the identification of any necessary learning brought about through clinical incidents and near-miss events
- Actively participate in the delivery of multi-disciplinary team (MDT) meetings within PCNs; responsible for preparatory admin, sending meeting invitations and taking notes of meetings.
- Undertake all mandatory training and induction programs
- Contribute to and embrace the spectrum of clinical governance
- Contribute to public health campaigns (e.g. flu clinics) through advice or direct care
- Liaise with professionals across Primary Care & Social Care and co-ordinate the PCN MDT meetings.
- Collate all a patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice
- Promote Care Co-ordination, its role in self-management, addressing health inequalities and the wider determinants of health.
- Raise awareness within the PCN of shared decision making and decision support tools and supporting people in shared decision-making conversations.
- Engage with and support the new and evolving agendas and service requirements across the PCN, including our work with Care Homes residents and the need to proactively manage their care in an individualised way.
- Undertaking clinical observations to support the plans, as appropriate.
- Build relationships with staff in the GP practices, attending relevant MDT meetings, giving information and feedback on health coaching.
- Provide education and specialist expertise to fellow PCN staff, ensuring they are made aware of care co-ordination, health and well-being coaching and social prescribing services and support colleagues to improve their skills and understanding of personalised care, behavioural appr