Pcn - Care Coordinator
2 weeks ago
Job summary An exciting opportunity has arisen for a Care Coordinator in the organisation, who must be available to work on a full-time basis with flexibility when required to work across sites within our Navigation PCN.
Main duties of the job Work within our network of GP Practices to provide a central co-ordination role for patient care planning.
The role will be GP facing, with the core responsibility being excellent patient care.Co-ordinate care packages for patients as identified by the GP across health, social care and mental health as appropriate, providing a single-point of access for staff & service users, actively managing patients care plan deliveryFacilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and supportIdentify and work with a list of named patients with the aim of encouraging independence, enabling people to remain at home, reducing unnecessary admissions to hospitals and supporting early discharge from hospital, improving the quality of care.
About us Coventry Navigation 1 PCN consists of 11 GP Practices covering approx.
90,000 patients.
Our network operates with in the city of Coventry.The successful candidate will join a Navigation 1 PCN Team and will be supported by a Seniors and Regular development sessions, teaching, training and opportunities to upskill will be provided.If you are a forward thinking individual who is keen to develop in this role, we want to hear from you
Job description Job responsibilities Job responsibilities1.
Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames2.
Explain the management of a patients pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms3.
Work closely with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated and of the patients care plan, without requiring a further referral from the GP.4.
Maintain accurate records and statistical returns as required by the ICB, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame.5.
Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations communications & patient notes and ensuring care packages are set up6.
Collect data on patients/carers for recognised outcome measure and document for service interpretation.
Ensure all patient notes are updated to reflect any changes, including details on plans7.
Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and lead the meetings.
Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance8.
Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.9.
Network and develop strong relationships with all levels of the NHSs key local players including the ICB, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sectorBe a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders Person Specification Qualifications Essential Relevant degree or equivalent level of training and experience Evidence of a consistent pattern of learning from education, training and experience Desirable Qualification in health or social care allied profession Skills & Abilities Essential Excellent written and oral communication skills Ability to develop effective professional relationships with others Develop own skills and knowledge and provide information to others to help their development Skills of assessing and interpreting service user conditions with appropriate actions Plan and organise complex activities or programmes requiring formulation and review Able to use Word, PowerPoint, clinical systems, email and /or willingness to learn The ability to multitask and mental adaptation to different unpredictable situations Desirable Ability to travel across sites Punctual and flexible across hours of work when required.
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