As a PCN Health Inequalities and Long Term Conditions Care Coordinator, you will play a vital role in helping individuals with health inequalities regain stability and improve their quality of life. Your main and overall responsibilities will include: Assessment and Planning:Conduct assessments of patients needs and develop Personalised Care Support Plans (PCSPs). Needs Assistance:Ensure patients are getting their annual health checks completed, supported in participation of national vaccination and cancer screening programmes, and assisted in accessing any other services that they may need Advocacy:Advocate on behalf of patients to access essential services, benefits, and housing opportunities. This includes supporting them to feel comfortable in attending their appointments & making reasonable adjustments. Referral Services:Connect patients to relevant community resources, health and social care, local carers support service, community navigation and working with and other healthcare & mental health services Documentation:Maintain accurate and up-to-date patient records and progress reports. The Care Coordinator responsibilities include but are not limited to the following: To work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients In collaboration with clinicians, administrative and reception team colleagues, to help patients with complex needs navigate the health and care system. This includes helping them 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 patients to utilise decision aids, help create single personalised care and support plans, in line with best practice. 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. Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure (PAM) Provide coordination and navigation for people and their carers across health and care services, including the use of digital tools. Support people to take up training and employment, and to access appropriate benefits where eligible; 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. Work closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Other key relationships include: City and Hackney Neighbourhood team, GP Confederation, social care, secondary care (Homerton and ELFT), community services, community and Clinical Pharmacists, City and Hackney CCG, Hackney Community and Voluntary sector and fellow care coordinators. Support the Clinical directors in the delivery of the DES specifications and support practices to reach proactive care targets Support practices in engaging patients in initiatives such as cancer screening, LTC checks, vaccination & immunisation uptake. Engage, attend and link in with the PCN community navigation team and the wider neighbourhood MDT meetings. EDUCATION, LEARNING AND DEVELOPMENT There is a requirement to comply with all organisational and statutory requirements (e.g. health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance). You will engage with appropriate training for Care Coordinators as set out by the Personalised Care Institute There is a requirement to engage in annual appraisal, developing objectives to inform a Personal Development Plan, which may include 360-degree appraisal and use of patient feedback. Support the practice staff and respond to requests for advice and assistance. Undertake additional training where necessary to provide enhanced services and participate in training programmes implemented by the PCN/practices as part of this employment. CONFIDENTIALITY In the performance of the duties outlined in this Job Description, the post-holder will have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the network. All information is to be regarded as strictly confidential. Maintain confidentiality of any information concerning patients in accordance with current policy on information governance. Demonstrate respect for privacy and confidentiality in all interactions with patients and the public. DATA PROTECTION If you are required to obtain, process and/or use information held electronically you should do 'it in a fair and lawful way. You should hold data only for the specific registered purpose and not use or disclose it in any way incompatible with such a purpose. Data must only be disclosed to authorised persons or organisations as instructed. SAFEGUARDING ADULTS AND CHILDREN The postholder has a duty to safeguard and promote the welfare of vulnerable adults and children. When adults or children and/or their carers use primary care services, it is essential that all adult and child protection concerns are both recognised and acted on appropriately. The postholder has a responsibility to ensure they are familiar with and follow local policies in relation to safeguarding vulnerable adults and that they follow the local child protection procedures and any supplementary guidance. The postholder has a responsibility to support appropriate investigations either internally or externally. To ensure the postholder is equipped to carry out their duties effectively, they must also attend vulnerable adult and child protection training and updates at the competency level appropriate to the work they do and in accordance with the local vulnerable adult and child protection training guidance. EQUALITY AND DIVERSITY Supports the equality, diversity, and rights of patients, carers and colleagues, that includes: Acting in a way that recognise the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation Respects the privacy, dignity, needs and beliefs of patients, carers and colleagues FLEXIBILITY This job description is not intended to be exhaustive. The care coordinator role within general practice is new and there will be extensive learning and adaptation throughout the contract period. The post-holder will be expected to adopt a flexible attitude towards the duties outlined which may be subject to amendment at any time in consultation with the post-holder and in line with the needs of the organisation. The post holder may be required to fulfil other duties, as agreed with the line manager/ clinical director to meet the needs of the organisation. This will involve travel to other sites within the organisation There will be some evening and weekend working requirements, which will be negotiated locally.