An exciting opportunity has presented for a motivated and enthusiastic Care Coordinator to work within a community mental health setting alongside our primary care colleagues.
The post holder will support the INT Leads, PCN Manager, Clinical Director and wider PCN team including the PCN's member practices and multidisciplinary team (MDT) within the PCN with project work as well as general core support to the PCN with a wide range of administration and associated tasks across the network. They will assist coordination of all key activity including access to services, advice, information, and ensuring health and care planning is timely, efficient, and patient-centred.
Our ideal candidate would be a committed team player as well as being able to work independently demonstrating initiative and passionate in promoting good quality care to maximize independence. Within this role, you will gain training, support, and guidance to ensure you are working collaboratively with external agencies to give the best possible care for our service users.
Main duties of the job
Responsibilities include but are not limited to the following:
1. Work closely with the INT Leads and PCN Manager in supporting the Clinical Director, PCN practices, and team in delivering the PCN Contract DES Specifications.
2. Understand the importance of engaging with external agencies to achieve high-quality care for our service users.
3. Undertake a wide range of administrative duties and provide administrative support to the Primary Care Network and team, including arranging MDT meetings, minute taking, and recording.
4. Assist the INT leads & PCN Manager with their relationships and engagement with the PCN practices and other stakeholders across the locality to ensure a collaborative approach to service development and delivery.
5. Build and maintain PCN clinics on Systmone along with booking and cancelling patient appointments.
6. Utilise population health intelligence to proactively identify and work with cohorts of patients across the PCN.
7. Maintain a proactive approach, with the ability to work on your own initiative and within a team environment.
8. This role requires the post holder to be based at Jubilee Gardens Medical Centre and have the ability to visit PCN practices if and when required.
About us
Northolt Primary Care Network started in 2019. We have 6 GP practices in the PCN. You will be working with 1 or more practices within the PCN.
You will be reporting to the INT leads, PCN Manager, and PCN Clinical Director. Your day-to-day clinical & non-clinical supervision will be received from the staff you will be reporting to as mentioned above.
We aim to provide high-quality accessible primary medical care, follow up-to-date guidelines for best clinical practice, ensure and support continued professional development of the Primary Health Care Team, provide an open, safe, and pleasant environment for staff and patients alike, and treat all patients in a polite, fair, and equitable manner.
Job responsibilities
As a PCN Care Coordinator, you will work closely with member practices and the PCN in offering a personalized approach to caring for social and psychological needs of identified patients on your caseload, ensuring appropriate support is made available to them and their carers, and addressing their changing needs.
You will also support other ARRS roles by contributing towards projects on an ad hoc basis to support health improvements to patients registered with member practices.
Your main duties will include:
1. Receiving and actioning referrals from a wide range of agencies, working with GP practices within the Primary Care Network (PCN), pharmacies, multi-disciplinary teams, hospital discharge teams, and allied health professionals.
2. Supporting the PCN in the delivery of the DES specifications, such as tackling health inequalities through targeted work with specific groups identified through population health management.
3. Supporting the coordination and delivery of MDTs within the PCN.
4. Utilising population health intelligence to proactively identify and work with a cohort of patients to deliver a personalized care approach.
5. Facilitating and ensuring the effective delivery of patient-centred, personalized health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames.
6. Providing coordination and navigation for patients and their carers across the spectrum of services available.
7. Working alongside other PCN Additional Roles staff and outside agencies to provide wrap-around support to patients.
8. Making appropriate third-party referrals and completing and maintaining accurate patient records.
This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to consider development within the practices. The post holder should be prepared to take on additional duties or relinquish existing duties to maintain the efficient running of the Network. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.
The role involves travelling to PCN member practices as required for service delivery.
Person Specification
Qualifications
* GCSE grade A to C in English and Maths
* Demonstrable experience of teamwork and IT skills.
* Experience of working in primary care.
* Worked as a key-worker/care coordinator or equivalent.
Experience
* Experience of working with all age functioning adults.
* Experience of working within a CPA framework.
* Experience of liaising with other teams or services, for example GPs, voluntary sector services.
* Experience of working in primary care or GP practice.
Additional Criteria
* Knowledge of assessment, planning, implementation, and evaluation of individualised care plans.
* Evidence of knowledge of current professional issues.
* Relevant professional Mental Health legislation/guidance. Basic theoretical concepts in nursing/social work.
* NICE guidelines, NSF, Clinical Governance.
* Must hold a full driving licence and have access to a car for work purposes.
* Awareness of current research in the field.
* Knowledge of Person Centred Care.
* Knowledge of audit process.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
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