Care Coordinator

Primary Care Networks are collaborations between groups of practices to develop services to improve patient care and reduce health inequalities.

Healthwest PCN is a mature PCN in the heart of Bristol, comprising Pembroke Road Surgery, The Family Practice, The Student Health Service and Whiteladies Health Centre.

We are looking for a highly motivated individual to support the PCN in the delivery of the DES specifications.

You will be part of a developing multi-disciplinary team (MDT). You will work closely with the MDT providing an efficient, professional, and flexible service to our patients. You will take a holistic approach to bringing together a patient’s care and support needs and draw up personalised care and support plans (PCSP).

You will support the PCN Manager in coordinating all key activity including access to services, advice and information, ensuring health and care planning is timely, efficient and patient-centred.

The role includes supporting digital initiatives while coordinating and navigating the patients’ journey through primary care. A key part of the role will be working with vulnerable and complex patients including regular liaison with local Care Homes.

Please note that this position will be mainly home based with occasional days in practice as required.

**Roles and responsibilities**

To work with the GPs and other primary care professionals within the PCN to proactively identify and work with a cohort of patients to deliver personal care.

To work closely and in partnership with the Social Prescribing Link Workers (SPLWs) and the wider Community Services including Sirona, to explore care options based on what matters to the person.

Pro-actively build relationships with outside providers to ensure good signposting for patients to access additional services.

To support patients to utilise decision aids in preparation for a shared decisions-making conversation and to help create single personalised care and support plans, in line with best practice.

To 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. This may include supporting people to take up training and employment, self-management education courses and access appropriate benefits where eligible.

To support people to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing, by utilising the Patient Activation Measure.

Being an initial contact point for ward rounds with nursing and residential homes, involving GP where needed

Support and feed into the development of the MDT approach to working with our patients

Becoming a contact point for patients who are:
- Complex and or frail
- Frequent visitors to the GP
- Recently discharged from hospital or about to be discharged
- Recently attended A and E and would benefit from follow up
- New patients to our list with follow up requirements
- Requiring active signposting to self-care services as part of on the day and minor illness approach

**Person Specification**
- Qualifications and Experience_

Evidence of a sound education to A level standard or equivalent

Evidence of a commitment to continuing professional development

Administrative support experience

Experience and success of communicating with people

Experience of working in teams; able to promote teamwork

Working in a computer environment
- Knowledge and Understanding_

Relevant knowledge of Primary Care Networks, General Practice and the wider Health and Social Care policies

An appreciation of the NHS agenda and Government targets
- Skills and Competencies_

Computer literate with an ability to use EMIS **(desirable) **and Microsoft office packages **(essential)**

Understand the aims of current healthcare policy within the PCN

Able to analyse, interpret and present data

Has attention to detail, able to work accurately

Has a planned and organised approach with an ability to prioritise their own workload to meet strict deadlines

Able to think analytically; anticipating obstacles and thinking ahead; using analytical techniques to draw logical solutions to problems

Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience

Excellent verbal and written communication skills with team members and other healthcare professionals. Whilst recognising people’s needs for alternative methods of communication

An excellent understanding of data protection and confidentiality issues
- Attributes_

Works effectively independently and as a member of a team

Continued commitment to improve skills and ability in new areas of work

Self-motivated and proactive

Able to undertake the demands of the post with reasonable adjustments if required

Independently mobile to be able to work across several sites and trave