PCN Care Coordinator

Join to apply for the PCN Care Coordinator role at NHS Job Summary An exciting opportunity has arisen within Primary Care for a Care Coordinator at The Confederation, Hillingdon CIC based at our Colne Union PCN in Yiewsley / West Drayton. We have one full‑time vacancy available on a permanent contract. The role requires the post holder to work on‑site with no home working. Care Coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long‑term conditions, to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to people and their carers. About Us The Confederation, Hillingdon CIC works with General Practice and other healthcare providers to deliver its vision for Hillingdon to deliver the best primary care outcomes for patients in the whole of London. We are a not‑for‑profit community interest company and aim to develop and support individual GP practices, PCNs and neighbourhoods. We deliver excellent clinical services, provide a provider representative voice for local General Practice, and are independent, innovative and transformational. Our Values We work together to make a difference for patients We care enough to go the extra mile We support, trust, and empower We sincerely value each other We support Primary Care to own its destiny Job Location Pembroke Centre, 90 Pembroke Road, Ruislip, HA4 8NX Pay & Benefits Salary: £25,000 to £33,000 a year, dependent on experience Contract: Permanent Working pattern: Full‑time Job Responsibilities Work with people, their families and carers, to improve their understanding of their condition. Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. Assist people to access self‑management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing. Provide coordination and navigation for people and their carers across health and care services, ensuring patients receive a joined‑up service and appropriate support from the right person at the right time. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long‑term health conditions, and refer back to other health professionals within the PCN when appropriate. Support the coordination and delivery of multidisciplinary teams with the PCN. Raise awareness of how to identify patients who may benefit from shared decision‑making and support PCN staff and people to be more prepared to have shared decision‑making conversations. Take referrals or proactively identify people who could benefit from support through care coordination. Have positive, empathetic, and responsive conversations with people and their families and carers about their needs. Increase patients’ understanding of how to manage and improve health and wellbeing by offering advice and guidance. Develop an in‑depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them. Use tools to measure people’s levels of knowledge, skills and confidence in managing their health and tailor support accordingly. Review and update personalised care and support plans at regular intervals and ensure they are communicated to the GP and other professionals and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes. Make and manage appointments for patients related to primary care. Help people transition seamlessly between secondary and community care services, conducting follow‑up appointments, and supporting people to navigate through the wider health and care system. Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues when there is an unaddressed clinical need. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the person’s care to ensure everyone is kept up to date and any issues or concerns are appropriately addressed. Actively participate in multidisciplinary team meetings in the PCN. Identify when action or additional support is needed, alert a named contact in addition to relevant professionals, and highlight any safety concerns. Record what interventions are used to support people and how people are developing on their health and care journey. Work with your supervising GP and/or line manager to undertake continual personal and professional development, review yearly progress, and develop clear plans to achieve results. Access regular clinical supervision to deal effectively with difficult issues that people present. Involved in one‑to‑one meetings with line manager regularly to discuss targets and outcomes achieved. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches. Act as a champion for personalised care and shared decision‑making within the PCN. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities. Adhere to organisational, practice and PCN policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Contribute to the wider aims and objectives of the PCN to improve and support primary care. Person Specification Qualifications GCSE in English and Maths IT literacy Experience Experienced Care Coordinator with EMIS experience Ability to actively listen, empathise with people and provide personalised support in a non‑judgemental way Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity Commitment to reducing health inequalities and proactively working to reach people from diverse communities Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders Ability to identify risk and assess and manage risk when working with individuals Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals or agencies Ability to maintain effective working relationships and to promote collaborative practice with all colleagues Ability to demonstrate personal accountability, emotional resilience and work well under pressure Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines Ability to provide motivational coaching to support people’s behaviour change Demonstrable commitment to professional and personal development Completed a two‑day PCI accredited care coordination training course or be willing to complete one prior to taking referrals Proficient in MS Office and web‑based services Excellent interpersonal, influencing and negotiating skills Excellent written and verbal communication skills Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and will be subject to a Disclosure and Barring Service check to confirm there are no previous criminal convictions. Employer Details Employer name: The Confederation, Hillingdon CIC Address: Pembroke Centre, 90 Pembroke Road, Ruislip, HA4 8NX Employer’s website: https://www.theconfederationhillingdon.org.uk #J-18808-Ljbffr