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Pcn Care Co-ordinator
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BOSVENA 3 Harbours Primary Care Network JOB DESCRIPTION POST TITLE: Care Coordinator LOCATION: General Practice within the Bosvena 3 Harbours PCN This role exists under the Primary Care Network Additional Roles Reimbursement Scheme JOB PURPOSE: To work closely with our PCN Practices and the multidisciplinary team in coordinating all key activities including access to services, advice, and information, and ensuring heath and care planning is timely, efficient, and patient-centred. The post holder will help to support patients to interact and engage with everyday life through activities designed to develop, maintain, or retrain skills for people with a cognitive, physical, or mental disorder, condition, or illness. You will support the provision of continuity of care and act as a point of contact for families, residents, and professionals for identified patients as part of the practice caseload. The job description and person specification are an outline of the tasks, responsibilities and outcomes required of the role.
The job holder will carry out any other duties as may reasonable be required by their line manager. PRIMARY DUTIES AND AREAS OF RESPONSIBILITIES Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribers, and other primary care professionals. Utilise population health intelligence to proactively identify and work with a cohort of patients to co-ordinate personalised care Support PCN and practice staff to be prepared to have shared-decision making conversations including utilising decision aids and tools, and support clinicians to understand the level of knowledge, skills and confidence for patients (their activation level) when engaging with their health and wellbeing. Help to co-ordinate and manage care needs through answering queries, making and managing appointments and where appropriate have written or verbal information to help patients make choices about their care Holistically bring together all of a persons identified care and support plan, in line with best practice, based on what matters to the person Where appropriate refer to people to take up training and employment, and to access appropriate benefits, education courses, peer support, and/or personal health budgets where applicable As part of the multidisciplinary team, build relationships with staff in the GP practices, attending relevant meetings, providing information and feedback on care coordination priorities Be proactive in developing strong link with local agencies, and in encouraging equality and inclusions Liaise directly with care homes and other key providers, and compile and circulate relevant information across stakeholder groups Understand, and adhere to safeguarding protocols for vulnerable individuals Capture key information to enable comprehensive and accurate records of support, inputting these into clinical systems as required and adhering to data protection legislation CONFIDENTIALITY The post holder may have access to confidential information relating to patients, their carers, practice staff and other healthcare workers.
They may also have access to information relating to the Federation as a business organisation. All such information from any source is to be regarded as strictly confidential. Information relating to patients, carers, colleagues, other healthcare workers or the business of the Federation may only be divulged to authorised persons in accordance with the Federations policies and procedures relating to confidentiality and the protection of personal and sensitive data. HEALTH & SAFETY The post holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Federations Health & Safety Policy.
EQUALITY AND DIVERSITY The post holder will support the equality, diversity and rights of patients, carers and colleagues to include - acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with the practice procedures and policies and current legislation. - Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
