Purbeck PCN Digital

Job summary

We are currently seeking a Care Coordinator to work 30 hours per week over 5 days supporting Digital services and the Enhanced Health in Care Homes Team (EHCH). You will be based from our PCN office situated within Wareham Health Centre on a Tuesday, Wednesday, and Thursday, however there is an opportunity to work remotely from home on a Monday and Friday if desired. You will be required to travel to our member practices at times to support the rollout of digital projects, therefore the post holder would need to be a car driver and have access to a car.

As a PCN Care Coordinator you will be a key member of the Care Coordinator team, focusing on supporting PCN multi-disciplinary teams to coordinate and deliver effective care for a variety of cohorts of patients. You will be expected to support the 6 member practices at any given time and therefore building effective relationships is key to this role as well as being adaptable to change.

Although you will be aligned to supporting Digitalservices and the EHCH Team, you will be required at times to support otherservices within the PCN such as but not limited to; Early Cancer Care,Diabetes, Pharmacy, FCP, and Spirometry.

Main duties of the job

The role of the care co-ordinator is to provide support for the PCN services and the 6 member GP Practices.

Duties for the digital aspect of this role will include using Population Health Management (PHM) data to improve and guide service improvements and reduce health inequalities. Assist with updating the social media and digital platforms for the PCN, promote digital inclusion for patients and promote the use of the NHS App, support the implementation of digital projects across the PCN and member practices such as BP@Home. You will also be the first point of contact for the Enhanced Health and Care Home Team. Managing the EHCH email account, creating visit lists for the EHCH Advanced Clinical Practitioners, assisting the EHCH Advanced Clinical Practitioners with administrative tasks following clinical visits such as sending referrals, updating clinical records and booking appointments.

About us

Purbeck PCN is made up of 6 member practices and works closely with the wider locality to improve and enhance patient care.

Purbeck PCN is committed to delivering an integrated neighbourhood team approach within the community and works to improve patient access to local services, by working with many sectors including the voluntary sector, mental health services, Help & Care, and Dorset Mind.

Job description

Job responsibilities

CARE COORDINATOR RESPONSIBILITIES & DUTIES

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.

Support patients to utilise decision aids in preparation for a shared decision-making conversation.

Holistically bring together all a persons 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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health.

Support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers.

Assist people to access self-management education courses, peer support or interventions that support them to take more control of their health and wellbeing.

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.

Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN.

Raise awareness within the PCN of shared decision-making and decision support tools.

Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.

DIGITAL RESPONSIBILITIES & DUTIES

The Digital Care Coordinator responsibilities & duties may include any or all of those listed below. Duties may vary from time to time under the direction of the PCN Leadership team, dependent on current and evolving PCN priorities and workstreams.

Work closely with PCN colleagues to identify patients who currently do not use digital channels for healthcare access, promoting digital inclusion and encourage the wider use of the NHS App.

Use available data sources to help the multidisciplinary teams understand the health and well-being profiles of our residents and to identify specific groups of patients and arrange care for them. This will include undertaking searches to identify individuals who meet particular criteria, for example patients requiring blood pressure monitoring.

Assist the PCN to deliver improvements to the services we provide our patients with relevant data and data analysis.

Support the PCN with coding activity appropriately and develop reports to demonstrate PCN activity.

Assist the PCN member practices to engage with hard-to-reach populations and to reduce health inequalities.

Take a lead in the deployment of new technologies and education of patients.

Run regular proactive reports to identify patients who may benefit from new services/new ways of delivering services and ensure appropriate referrals are made.

Work with colleagues and partner organisations to promote digital inclusion, for example, by demonstrating to and educating colleagues about how to optimally use digital technologies and data/intelligence.

Support the PCN Administrator to develop social media content for the PCN including website, Facebook - promoting ARRS roles, services and health campaigns.

Providing data administration support to the PCN Leadership team and member practices as required.

Any reasonable requests from the PCN Leadership team.

Act as an ambassador for use of digital healthcare technology with both patients and colleagues.

Support PCN and member practices with handling and analysing data and developing our digital maturity.

Support partner practices to maintain and monitor data coding and quality on clinical systems, ensuring coding is compliant and consistent.

Run system reports and extract data as required by the PCN for activity reporting, using SystmOne clinical system, PCN digital dashboard and other data sources.

Be a point of contact for digital enquiries and be an active member of the NHS Dorset Digital CoP.

Under the direction of the PCN Leadership team, support the implementation of digital projects across the PCN and member practices.

EHCH RESPONSIBILITIES & DUTIES

You will work closely with the EHCH Advance Nurse Practitioner to manage patient lists for the upcoming days/weeks, ensuring contingency plans are in place and followed for unexpected leave.

Liaise directly with care homes for non-clinical tasks such as booking and managing ward round lists for clinical staff within the PCN SystmOne module.

Upon request you will provide patient lists to the EHCH Advance Nurse Practitioner in advance of planned visits for monthly GP ward rounds.

Managing the EHCH inbox daily and dealing with requests in a timely manner. You will be required to follow a SOP for referral requests and need to deal with non-clinical enquires the care homes may have. You will also be required to send confidential and encrypted emails at times.

You will be responsible for escalating clinical enquiries to the EHCH Advance Nurse Practitioner in a timely manner.

Responsible for registering new care home patients as per the SOP in Practice SystmOne modules.

If required, arrange the weekly MDT meeting on behalf of the EHCH Advance Nurse Practitioner.

Produce reports such as, but not limited to; care home bed capacity numbers, monthly clinician appointment numbers and anything else requested by the EHCH Advance Nurse Practitioner.

Person Specification

Qualifications

Essential

Educated to at least GCSE level or equivalent

Desirable

Health and wellbeing qualification or equivalent experience

Experience

Essential

Good understanding of health and social care. Digitally literate with good working knowledge of digital systems and processes. Proven experience of working with the general public in a similar role. Experience of working in a service provision and/or healthcare organisation.

Desirable

Experience working with vulnerable adults. SystmOne experience. Microsoft applications including MS Teams. Project management experience/setting up of a new service.

Skills

Essential

Empathic and caring; sensitive to peoples life stages, concerns and problems. Motivated to achieve good outcomes for people/patients. Excellent written and verbal communication skills. Good IT skills, able to use relevant Office packages (Word, Excel, Databases and Outlook for email/calendar). Organised with effective time-management skills. Able to problem solve, analytical skills. Able to follow policies and procedures effectively. Able to maintain confidentiality at all times. Good inter-personal and customer care skills. Positive approach, calm under pressure. Flexible in approach, willing to try new/different techniques/approaches. Ability to work both as a team and autonomously and with a hybrid approach to work-base.

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