Bhr Pcn Ltc Care Coordinator

Main duties of the job

Working in BHR PCN

How will the role help tackle health inequalities,caring for patients with three or more long-term conditions (multimorbidity) is a priority for BHR PCN.This is a challenging but very rewarding opportunity for someone to join our committed and dedicated team that tackle these health inequalities daily. Our population have a higher prevalence of mixed mental and long-term conditions because of the nature of our more deprived communities, particularly at an earlier age. Along with our culturally diverse population, these multimorbidity patients are typically our hard-to-reach patients. The role will support patients to stay well and manage their condition by working very closely with their GPs.

About us

**Job Summary**

The Care Coordinator will be part BHR PCN Multi-Disciplinary Team (MDT) who are responsible for managing the care of people registered with practices within BHR PCN.

The care coordinator will provide support to practices within the PCN to manage, identify and provide coordination of care for the PCN cohorts of patients. The approach ensures that a role is focused on proactively seeking frameworks and models of care for these priority patients within the PCNs and its local context.

The Care Coordinator will support the PCNs approach to health population management by coordinating routine care by prioritising patients in highest risk group, delivering strategies that engage wider workforce and digital/tech to optimise self-care and remote care.

The Care Coordinator will also be central to developing solutions to unplanned care by understanding what factors are driving poor outcomes in different population groups. Ensuring the PCNs are designing and planning models of care which will improve health and wellbeing today and in the future.

This will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCNs population.

Job descriptionJob responsibilities

The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with Long Term Conditions. An ethos of promotion of independence and partnership-working is integral to this post.

**Primary Duties and Areas of Responsibility**
- Holistically supports patients with LTCs and their carers within the community.
- Ensure patients care plans are agreed and personalised.
- The role provides an accessible point of contact for guidance, support and navigation whilst working closely with health, social care, and voluntary agencies.
- Liaise with all clinical and non-clinical members in the MDT.
- Support reporting to strategic team any systematic trends of potential threats and their implications or opportunities and likely future developments.
- Be organised in performing administrative tasks (including patient registers, patient appointments, and referrals to other services.

**Patient Identification**
- Receive and collate information from clinical systems to understandwhat factors are driving poor outcomes in different population groups.
- Use search tools for risk stratify patients.
- Review end of year PQI data for the PCN.

**Maintenance of IT based information systems and responsibility for key performance data**:

- To ensure the IT requirements for recording activity are adhered to in collaboration with other team members.
- Accurate update and maintenance of GP systems within the MDT.
- To provide agreed performance/activity data within the MDT and PCN and wider BHR PCN.

**Communication and collaborative working relationships**
- Demonstrates ability to work as a member of a team.
- Can recognise personal limitations and refer to more appropriate colleague(s) when necessary.
- Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.
- Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations.
- Work with service users, PCN practices and partners
- Develop excellent working relationships with all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT.
- Meet regularly with the clinical lead and review prioritisations.
- Keep the MDT and BHR PCN abreast of good news stories.
- Manage and prioritise workload daily and deal with the competing demands.

**Other responsibilities**
- To always act in an anti-discriminatory manner
- To be able to plan and respond to workload according to operational priorities.
- To support the delivery of these functions across wider locality areas where necessary
- To undertake any training required i