Care Co-ordinator Moorlands Rural Pcn

8 months ago

StokeonTrent, United Kingdom North Staffordshire GP Federation Full time

**Job Overview**: To work closely with teams to help and support the multi-disciplinary team (MDT) meetings and the ongoing patient case management. This will involve linking with GP surgeries and a range of Community Health Services. Support the Primary Care Network (PCN) to deliver effective, co-ordinated care for vulnerable children and adults, particularly those at high risk of a hospital emergency admission, emergency department (ED) attendances or out of hours care. We are looking for someone who is hardworking, organised with great interpersonal skills who will be committed to delivering the highest quality of care for our PCN.

If you have what it takes and have the experience as follows, we would like to hear from you. Experience in patient focused environment Evident of experience in wide range of administrative systems and software programmes Experience of planning and organising complex meetings / agendas Evidence of working with IT systems Evidence of ability to support collation and analysis of data Evidence of supporting vulnerable children and adults in challenging situations Excellent verbal and written skills Ability to provide and receive complex information Experience of working in a GP practice dispensary Excellent interpersonal skills Excellent team player Job Description: 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 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 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 counselling needs. Support people to understand their level of knowledge, skills, and confidence (their 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 interventions that support them in their health and wellbeing and increase their activation level 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 Administrative Responsibilities: 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 Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations To work as a key member of the MDT to help support the development patient centred care. Act as a contact to assist with case management of patients at risk of admission, providing support and counselling in liaison with GPs.

To cross reference the patients identified as high risk within the practice to support case managers and key workers in developing any necessary care plans including prevention of carer breakdown To work with the wider MDT to identify appropriate support for high-risk patients to ensure that patients are reviewed, and any plans are developed Ensure that all patients Care Plans, diagnostics results, and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available To liaise with acute hospitals, cross referencing admission data with the at-risk list and coordinating the sharing of key information between the acute hospital teams and the community services. Support with practices with referrals to CAMHS or any appropriate support groups Personal/Professional development: Participate in any training programme implemented by the PCN as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work To work in accordance with health and safety policies and procedures including reporting and recording any health and safety incident or accident Adhere to host employer's adult and children safeguarding policies and procedures This job description is not exhaustive, and duties may vary with the requirements of the PCN. Due

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