Primary Care Network Care Coordinator
17 hours ago
**Key Responsibilities and Duties**: The Care Coordinator will undertake work in line with PCN and directed priorities. The following are the core responsibilities of the role: Clinical Pharmacy Support Use clinical system risk stratification tools and Ardens Manger to identify and call/recall patients for the Clinical Pharmacy Team to review. This includes, but is not limited to, patients for: Structured Medication Reviews QOF Quality Improvement indicators QOF Medicines indicators IIF Medicines indicators Practice Prescribing Schemes Audits Early Cancer Diagnosis Support the delivery of PCN objectives under the Early Cancer Diagnosis requirements of the PCN DES. This includes but is not limited to: Attending Cancer Steering Group meetings Patient follow-up from cancer screening Cancer care planning Patient communications Enhanced Care in Care Homes You will: Support the practice team to identify gaps in existing care plans and help produce and annual Personalised Care and Support Plan (PCSP), referring to the patients named GP to complete.
Liaise with care homes to schedule the monthly Clinical Pharmacist visits. Liaise with care homes to ensure new admissions and patients who have been discharged from hospital, are reviewed at the next Ward Round, and have an updated PCSP. Cardiovascular Disease Prevention and Diagnosis Support patient call and recall as directed by the Senior Network Manager. Health Inequalities Identify patient cohorts being targeted by the PCN health inequalities steering group, inviting them to participate in agreed interventions.
Learning disabilities care planning. Supporting patients & Social Prescribing: Actively sign-post patients to a variety of services including Social Prescribing, making referrals as appropriate. Utilise population health intelligence to proactively identify a cohort of patients to deliver personalised care. Information Technology Write searches to identify target patient cohorts.
Write and update templates and protocols to effectively capture relevant clinical and non-clinical information. Multi-Disciplinary Team (MDT) Meetings Prepare agendas for MDT meetings and contact all parties to ensure attendance and to confirm patients to be discussed. Care Planning Support the practice objectives (local and PCN-level) to ensure care plans are actively created and updated. This includes for learning disability patients, dementia patients, care home residents and cancer patients.
Identify patients without recent care plans in place and work with their name GP to update these plans. Ensure that preventative actions are agreed and detailed in care plans to support the reduction of unnecessary hospital admissions. Investment and Impact Fund (IIF) Support patient call and recall as directed by the Senior Network Manager. Ensure the minimum number of patient contacts by aligning multiple tests and reviews.
**Support Data Collection**: Ensure timely and accurate collation of data for the PCN Appropriate management of collected data, ensuring all data is kept and shared in accordance with all relevant governance requirements. Validate and quality assure incoming data. Run regular patient searches using clinical systems to have an up-to-date record of progress of achievement of Key Performance Indicators (KPIs). Case finding to support target achievement and enhancing register prevalence.
PCN Duties Provide an agreed Care Coordinator service to all PCN practices with duties to be defined by the PCN managers.
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