Care Coordinator- Maple Primary Care Network

**MAPLE Primary Care Network**

**Central Aylesbury**

**Salary £21,892.00-£24,157.00 FTE dependant on experience**

**Working hours: 37.5 hours per week**

**NHS Pension**

**33 days annual leave inclusive of bank holidays**

Do you love working with the wider community? Passionate about the services and treatment patients receive? An exciting opportunity has arisen for a care coordinator to join our already established, growing and committed team in providing additional care and services across our PCN patient populations, including the provision of support and enhanced care to vulnerable patients and patients in residential and nursing home settings.

We are looking for a compassionate, collaborative and motivated coordinator to support the delivery of care to vulnerable patients and care homes, coordinating the work of healthcare professionals and non-clinical staff involved in the care of patients.

You will be joining a thriving existing PCN team of care coordinators, social prescribers and health and wellbeing coaches and be an integral part of the team when it comes to delivering the best patient care. You also will be an essential part of a dynamic and forward-thinking multidisciplinary team spanning wider PCNs, Community Services and Local Authority, working to provide enhanced care to these groups of patients.

**Primary Duties and Areas of Responsibility**
- utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
- serve as the contact point, advocate and informational resource for patients, care teams, family /caregivers and community resources, responding with empathy and respect and signposting where appropriate.
- ensure regular and consistent communication with care homes regarding patient progress.
- support patients to utilise decision aids in preparation for a shared decision-making conversation.
- acknowledge patients’ rights on confidential issues; maintain patient confidentiality at all times.
- holistically bring together all of a person’s identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
- help people to 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.
- visit patients in community, home or care home setting to assess and discuss their care needs involving carers as appropriate.
- support people to take up training and employment, and to access appropriate benefits where eligible.
- support people to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure.
- assist with the identification of ‘high risk’ patients and keep a register of the teams’ workload.
- assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.
- undertake visits or arrange appointments at their Practice for patients on the PCN’s case load or otherwise as directed by the Duty Doctor following identification of urgent and non-urgent clinical need to assess, diagnose, treat, prescribe and refer appropriately according to the patient’s health needs and acting within the PCN’s clinical skill set.
- explore and assist people to access personal health budgets where appropriate.
- provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals.
- refer through to the appropriate member of the team, and/or make referrals on behalf of the team.
- support the coordination and delivery of multidisciplinary teams (MDTs) within the PCN, to include management of the team diaries and arrangement/planning of team meetings and producing reports as requested.
- liaise with members across all practices within the PCN, supporting good communication.

We are a federation of 45 GP practices covering a population of over 485,000 patients across Buckinghamshire. We began in 2016 and now employ around 200 members of staff across our head office sites, and our planned and unplanned care services.

As a GP Federation, we are proud to represent our member practices and to champion primary care by working with local general practice and system partners in the provision of community-based healthcare services. We are dedicated to providing safe and compassionate care to our patients across our range of primary and unplanned healthcare services in Buckinghamshire, and believe in continuous commitment to quality service delivery and positive patient outcomes.

Pat