PCN Care Coordinator
2 weeks ago
As a PCN Care Coordinator, you will be part of the Primary Care Multidisciplinary Team, offering a personalized approach to caring for the social and psychological needs of identified patients on your caseload, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
Main Duties- Create a positive working environment in which equality and diversity are professionally managed, dignity at work is upheld, and staff can do their best.
- Work alongside other ARRS roles to effectively perform the role and develop throughout by attending supervision sessions, appraisal meetings, and training/development days.
- Ensure that Standard Operating Procedures (SOPs) are adhered to, supporting in the delivery of service and completing reviews and updates with the PCN management team.
- Utilize adequate knowledge around primary care to meet the required needs of the service.
- Support the other ARRS staff/PCN management team to develop quality of work and keep detailed records of day-to-day tasks, including managing caseloads.
- Encourage good teamwork throughout the partnership and with each of the GP surgeries and contributing to the Enhanced Health for Care home.
We are a Primary Care Network (PCN) of six practices working together with a range of local providers, including primary care, community services, social care, and the voluntary sector, to offer more personalized, coordinated health and social care to their local populations.
Our PCN comprises 49,348 patients over the six practices.
The aims of a network are to:
Protect, improve, and extend local General Practice through greater organisational scale to provide convenient high-quality, comprehensive, and integrated services.
Enhance the skills and flexibility of the General Practice workforce to meet population and service needs with programmes of continuing professional development.
Work and collaborate with others to innovate in service provision, building on new technologies and recognising lifestyle choices of service users in the way in which they wish to access care.
Job ResponsibilitiesAs a PCN Care Coordinator, you will work closely with member practices and the PCN in offering a personalized approach to caring for social and psychological needs of identified patients on your caseload, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
You will also support other ARRS roles by contributing towards projects on an ad-hoc basis to support health improvements to patients registered with member practices.
Your main duties will include:
Receiving and actioning referrals from a wide range of agencies, working with GP practices within the Primary Care Network (PCN), pharmacies, multi-disciplinary teams, hospital discharge teams, and allied health professionals.
Utilizing population health intelligence to proactively identify and work with a cohort of patients to deliver personalized care approaches.
Facilitating and ensuring the effective delivery of patient-centred, personalized health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames.
Providing coordination and navigation for patients and their carers across the spectrum of services available.
Supporting local Care Homes to manage patient needs, including completing/reviewing Care Home Care Plans and Dementia reviews as required, contributing to Care home ward rounds.
Completing Annual Learning Disability reviews on behalf of the practice.
Undertaking assistance where clinicians visit to see patients in their own homes, where applicable, for Blood Pressure checks, welfare checks, and provide support.
Working alongside other PCN Additional Roles staff and outside agencies to provide wrap-around support to patients.
Making appropriate third-party referrals.
Completing and maintaining accurate patient records.
This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to consider development within the practices. The post holder should be prepared to take on additional duties or relinquish existing duties to maintain the efficient running of the Network. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.
The role involves travelling to PCN member practices as required for the service delivery.
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