PCN Care Coordinator

3 weeks ago

Nuneaton, United Kingdom Rural Warwickshire North PCN Full time

Job summary

As a PCN Care Coordinator you will be part of thePrimary Care Multidisciplinary Team, offering a personalised approach to caringfor the social and psychological needs of identified patients on your caseload,making sure that appropriate support is made available to them and theircarers, and ensuring that their changing needs are addressed.

You will work closely with the GPs and othermembers of the practice and PCN teams to ensure the coordination and managementof identified patients at all points of their care journey.

Main duties of the job

Create a positive working environment in which equality and diversity are professionally managed, dignity at work is upheld and staff can do their best; Work alongside other ARRS roles to effectively perform the role and develop throughout by attending supervision sessions, appraisal meetings and training / development days. Ensure that Standard Operating Procedures (SOPs) are adhered to supporting in the delivery of service and completing reviews and updates with the PCN management team. Utilise adequate level of knowledge around primary care to meet the required needs of the service. Support the other ARRS staff/PCN management team to develop quality of work and keep detailed records of day-to-day tasks including managing caseloads. Encourage good teamwork throughout the partnership and with each of the GP surgeries and contributing to the Enhanced Health for Care home.

About us

We are a Primary Care Network ( PCN ) of six practices working together with a range of local providers, including primary care, community services, social care, and the voluntary sector, to offer more personalized, coordinated health and social care to their local populations.

Our PCN comprises of 49,348 patients over the six practices

The aims of a networks are to:

Protect, improve, and extend local General Practice through greater organisational scale to provide convenient high quality, comprehensive and integrated services.

Enhance the skills and flexibility of the General Practice workforce to meet population and service needs with programmes of continuing professional development.

Work and collaborate with others to innovate in service provision, building on new technologies and recognising lifestyle choices of service users in the way in which they wish to access care.

Our PCN comprises of 49,348 patients over the six practices

Hazelwood Group Practice

27 Parkfield Road, Coleshill B46 3LD

Pear Tree Surgery

28 Meadow Close, Kingsbury, Tamworth B78 2NR

Dordon and Polesworth Group Practice

162 Long Street, Dordon, Tamworth B45 1QA

Satis House Medical Practice

10 Birmingham Road, Water Orton B46 1TH

Chancery Lane Surgery

Chancery Lane, Chapel End, Nuneaton CV10 0PB

Camp Hill Surgery

Ramsden Avenue, Nuneaton CV10 9EB

Job description

Job responsibilities

Asa PCN CareCoordinator, you will work closely with member practices and the PCN inoffering a personalised approach to caring for social and psychological needsof identified patients on your caseload, making sure that appropriate supportis made available to them and their carers, and ensuring that their changingneeds are addressed.

You will alsosupport other ARRS roles in delivering PCN DES by contributing towards projects on an adhoc basis to support health improvements to patients registered with memberpractices.

Your main duties will include:

Receiving and actioningreferrals from a wide range of agencies, working with GP practices within thePrimary Care Network (PCN), pharmacies, multi-disciplinary teams, hospitaldischarge teams and allied health professionals (list not exhaustive);

Utilise populationhealth intelligence to proactively identify and work with a cohort of patientsto deliver personalised care;

Facilitate and ensurethe effective delivery of patient-centred, personalised health and social careplans for patients, monitoring progress and reporting outcomes, contributing topatient reviews and care planning within appropriate time frames;

Provide coordinationand navigation for patients and their carers across the spectrum of servicesavailable;

Support local CareHomes to manage patient needs, including completing/reviewing Care Home CarePlans and Dementia reviews as required, contributing to Care home ward rounds

Complete AnnualLearning Disability reviews on behalf of the practice;

Undertake visits to seepatients in their own homes, where applicable, for Blood Pressure checks,welfare checks and provide support;

Work alongside otherPCN Additional Roles staff and outside agencies to provide wrap-around supportto patients;

Make appropriate third-partyreferrals; and

Complete and maintainaccurate patient records.

This job description is intendedto provide an outline of the key tasks and responsibilities only. There may beother duties required of the post-holder commensurate with the position. This description will be open to regularreview and may be amended to consider development within the practices. The post holder should be prepared to take onadditional duties or relinquish existing duties to maintain the efficientrunning of the Network. This jobdescription is intended as a basic guide to the scope and responsibilities ofthe post and is not exhaustive. It willbe subject to regular review and amendment as necessary in consultation withthe post holder.

The roles involves travelling to PCN member practices as required for the service delivery.

Person Specification

Experience

Essential

1.Ability to manage and prioritise a caseload 2.Ability to work flexibly and enthusiastically within a team or on own initiative communication skills, both written and verbal 4.Ability to build relationships with patients, their families and carers 5.Ability to provide personalised support to individuals, their families and carers 6.Ability to listen and empathise with people in a non-judgmental way to provide leadership and complete tasks in a timely manner to maintain effective working relationships and promote collaborative working 9.Ability to communicate difficult messages to patients and families

Desirable

Experience of using clinical systems such as EMIS Web

Qualifications

Essential

GCSE Grade C or above in Maths and English, or equivalent qualification

Desirable

NVQ Level 3, Advanced Level or equivalent or working towards and a commitment to professional and personal development

Personal Qualities

Essential

Full UK driving licence and access to a car The post-holder is required to travel independently between practice sites (where applicable) and to attend meetings hosted by other agencies.

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