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Lowestoft PCN Care Co-Ordinator

3 months ago


Lowestoft, United Kingdom Bridge Road Surgery Full time

Job summary

Lowestoft PCN has a patient population of approximately 80,000 across 7 practices. We aim to provide high quality services adhering to principles of best practice, promoting equal opportunities and working positively with diversity.

The Care Coordinator will support the practice and Primary Care Network (PCN), working within professional and clinical boundaries as part of an established multi-disciplinary team, to deliver timely and personalised care for patients and deliver key objectives of the Primary Care Network DES. This post will particularly be supporting patients with long term health conditions and/or complex health needs and those with an early cancer diagnosis. The position will aid our cancer care quality improvement work by supporting the practice and PCN to improve their processes, achieve their targets and working with patients to help them ensure they have the right support at each stage of their journey.

The PCN Care Co-ordinator should be prepared to work as a team member with other care co-ordinators within Lowestoft for all of Lowestoft patients. The successful applicant should be prepared to work in any Lowestoft practice, but primarily will be based in the High Street Surgery.

Main duties of the job

Care Coordinators support patients in preparing for or following up on clinical conversations with healthcare professionals. They work closely with GPs and other primary care colleagues to ensure that patients receive personalised care and support to proactively manage their health. This varied role will involve gathering relevant information and data about a patients health to support review appointments, preparing personalised care plans and liaising with the Social Prescribing Link Workers to ensure patients can access non-clinical support in the community. This can also include building up knowledge about benefits available to patients. Patients are contacted by a variety of methods including email, other electronic access systems, letters, telephone, video or face to face contact.

One part of the role will be as cancer care co-ordinator. This involves co-ordinating the monthly GSF/cancer care meeting and actioning admin work as part of the end-of-life care, keeping in contact with patients as well as the community palliative care team. It will include audit searches and ensuring QOF data collection.

The care co-coordinator will also be involved in triaging, signposting and care navigation of patients within the developing capacity and access work undertaken by the PCN

About us

Lowestoft PCN includes the following practices working together to provide and promote healthcare for the patients of Lowestoft. We are passionate about delivering high quality services. The practices are Andaman Surgery, Rosedale and Kirkley Mill Surgery, Alexandra Road and Crestview Surgery, Bridge Road Surgery, Victoria Road Surgery and High Street Surgery

Job description

Job responsibilities

Job responsibilities

Main duties of the job

Care Coordinators support patients in preparing for or following up on clinical conversations with healthcare professionals. They work closely with GPs and other primary care colleagues to ensure that patients receive personalised care and support to proactively manage their health. This varied role will involve gathering relevant information and data about a patients health to support review appointments, preparing personalised care plans and liaising with the Social Prescribing Link Workers to ensure patients can access non-clinical support in the community. Patients are contacted by a variety of methods including email, other electronic access systems, letters, telephone, video or face to face contact. The Care Coordinator will be involved in triage, sign posting and care navigation of patients.

Primary Duties and Areas of Responsibility

Support practices to deliver their quality improvement plans for early cancer diagnosis.

Develop and embed systems across the network to improve cancer screening uptake, liaising with external agencies as appropriate

Utilise population health intelligence to proactively identify and work with patients newly diagnosed with cancer and on the cancer register to deliver personalised care;

Ensure patients receive a Cancer Care review in line with national defined timescales and targets.

Support the practices in your practice/PCN in conducting peer to peer learning events that look at data and trends in diagnosis across the practice/PCN, including cases where patients presented repeatedly before referral and late diagnoses

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

Holistically bring together all of 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

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 when engaging with their health and wellbeing

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

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

Support the coordination and delivery of MDTs within the practice/PCN

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

Raise awareness within the practice/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 practice/PCN staff and patients to be more prepared to have shared decision-making conversations

Safeguard patients by ensuring organisations and groups to whom its Care Coordinator directs patients have basic safeguarding processes in place for vulnerable individuals and provide opportunities for the patient to develop friendships and a sense of belonging, as well as to build knowledge, skills and confidence

Person Specification

Experience

Essential

See full job description and person specification for details

Desirable

See full job description and person specification for details

Communication

Essential

- Excellent interpersonal and organisational skills - Excellent interpersonal and communication skills, able to influence and - persuade others articulating a balanced view and able to constructively question information - Ability to negotiate effectively - Build effective relationships with a range of people which are based on - openness, honesty trust and confidence

Desirable

- Clear communicator with excellent writing, report writing and - presentation skills; capable of constructing and delivering clear ideas and concepts concisely and accurately for diverse audiences

Qualifications

Essential

Educated to GCSE Level

Desirable

Previous General Practice Experience

Personal Attributes and Abilities

Essential

- Ability to co-ordinate and prioritise workloads - Able to multi-task as well as be self-disciplined and highly motivated - Commitment to quality and best practice - Flexible and adaptable - Team player

Desirable

- Ability to cope with unpredictable situations - High degree of personal credibility, emotional intelligence, patience and flexibility - Demonstrates a flexible approach in order to ensure patient care is - delivered - Willingness to attend meetings when required - Smart and presentable - A polite and helpful manner - Honesty and Integrity - A mature and responsible attitude to work