Bhr Pcn Long Term Condition Care Coordinator

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 in order to maintain competency including mandatory training.

To contribute to, and work within a safe working environment. The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures. The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required. The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident, or potentially hazardous environment.

Patient Care Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding. Effectively use all methods of communication and be aware of and manage barriers to communication. Effectively recognise and manage challenging behaviours, carers and or relatives Provide information to patients, their carers and/or relatives on behalf of the team. Supporting Care Delivery Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated.

Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc. Follow through with service users and others involved to ensure all services and care arrangements are in place. Autonomy/Scope within Role The post holder will be required to work within clearly defined organisational protocols, policies, and procedures. Key Relationships Key Working Relationships Internal: Clinical Lead for the PCN GPs and General practice teams within the PCN PCN Clinical Director MDT members including but not exhaustive: Clinical Pharmacists, technicians, Physician Associates, Physios, Paramedics, Social Prescribing Link Workers, Patient Ambassadors, Nurse Teams.

**Key Working Relationships External**: GPs from neighbouring PCN Service providers Social care Voluntary services Patients/service users Carers/relatives Health and Safety/Risk Management The post-holder must co