Care Coordinator Specialist

2 months ago

Doncaster, Doncaster, United Kingdom Primary Care Doncaster Ltd Full time
Job Summary

The North West PCN Care Coordinator will work closely with the PCN and Practice Team to support the multi-disciplinary team (MDT) meetings and ongoing patient case management.

Main Responsibilities
  • Utilize population health intelligence to proactively identify and work with a cohort of patients to deliver personalized care.
  • Support patients in utilizing decision aids in preparation for shared decision-making conversations.
  • Holistically bring together all of a person's identified care and support needs, and explore options to meet these within a single personalized care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
  • Help people 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 in taking up training and employment, and accessing appropriate benefits where eligible.
  • Support people in understanding their level of knowledge, skills, and confidence (their "Activation" level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure.
About Us

Primary Care Doncaster (PCD) Ltd is developing a wide range of services to support general practice across the city and is looking at innovative ways to develop its workforce, due to interest by a significant number of GP practices and Networks within the city.

At PCD and within the GP practices and Networks, we believe in the power of collaboration and the creativity that thrives when people work together in person. Each Network has a range of offices and work locations designed to foster innovation, teamwork, and a vibrant work culture where you can grow your career and make a real impact.

As a PCD employee, you will have access to the generous NHS Pension Scheme and 27 annual leave days per year.

PCD is an equal opportunities employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Job Requirements
  • Explore and assist people in accessing 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.
  • Support and undertake group consultations and sessions as required.
  • 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.
  • Work as a key member of the MDT to help support the development of effective MDT meetings.
  • Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers.
  • Ensure that action points identified within the MDT are recorded and followed up.
  • Under guidance from their line manager, take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team.
  • Cross reference the patients identified as high risk with the carers register within the practice to support case managers and key workers in developing holistic anticipatory care plans including prevention of carer breakdown.
  • Work with the wider MDT to identify appropriate case managers for high risk patients to ensure that patients are reviewed and anticipatory care 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.
  • 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.
  • Under the guidance of case managers, assist with the discharge process to reduce length of stay in the acute/community hospital setting.
  • Support project management and lead on projects as required.

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