Drake Medical Alliance Primary Care Network
Care Coordinators play an important role in the PCN by identifying and supporting patients manage their long-term health conditions. Care Coordinators work closely with GPs and practice teams to manage a caseload of patients, ensuring that appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
The role of Care Coordinator provides support to the practice by being a supportive link between the reception team and the clinicians to provide the best outcome for the patient. The workload can vary between managing invites for health reviews, arranging appointments and managing referrals to social prescribing link workers, health and wellbeing coaches and other professionals where appropriate.
The role also involves collaborative working with our PCN pharmacy service which can include project work such as identifying patients, arranging and analysing metrics required for the pharmacy team to assess their medication needs.
NB: This is NOT a 'hands-on care' role - it is an administrative role that includes patient contact mainly by phone.
Main Duties of the Job
1. Contacting patients by telephone, email, text message, or letter to make appointments for Health Care Assistants, Nurses, Nurse Practitioners, GPs as required for long-term condition management as specified by practice.
2. Support triage of information received via AccuRx or via other platforms.
3. Administration support for the practice team.
4. Use internal and external email and the internet to keep up to date and send and receive messages.
5. Supporting patients with referral to external services such as Social Prescribing and befriending services.
6. Respond, using a helpful and problem-solving approach, to all queries and requests for assistance from staff and other visitors.
7. Use SystmOne to access patient records, book blood tests and arrange routine appointments with the appropriate clinician.
8. 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.
9. Provide expertise to address both the public health and social care needs of patients, including lifestyle advice, service information, and help in tackling local health inequalities.
10. Ensure appropriate onward referral of urgent issues to an appropriate clinician.
11. Support the coordination and delivery of multidisciplinary teams.
12. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients in having these conversations.
13. Maintain records of referrals and interventions to enable monitoring and evaluation of service.
14. Ensure appropriate SNOMED codes are used to record activity.
15. Have a positive, empathetic, and responsive conversation with the person, and their family and carer(s) about their needs.
16. Work towards increasing patients' understanding of how to manage and develop health and wellbeing through offering advice and guidance.
17. Work with the wider PCN, MDTs and the social prescribing service to look at how to support patients requiring personalised care and support.
18. Support patients as guided by the practice to manage health inequalities.
19. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
20. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system.
21. Refer onwards to social prescribing link workers and health and wellbeing coaches where required.
22. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the person's care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
23. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate.
24. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
25. Record what interventions are used to support people, and how people are developing on their health and care journey.
26. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
27. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning.
28. Work in accordance with the practices and PCN's policies and procedures.
29. Contribute to the wider aims and objectives of the PCN to improve and support primary care.
Person Specification
Skills
* Prioritise and work to deadlines.
* Work effectively and collaboratively as part of a team but also autonomously.
* High level and adaptable communication skills across a range of individuals of all ages, backgrounds and cultures with varying social and emotional needs.
* Understanding the impact of economic and environmental factors on people's health and wellbeing.
* Promote and maintain good working relationships with a variety of external partners.
* Keep accurate records of discussions and clearly replicate discussions in writing.
* Work on own initiative but within constraints of the role.
* Full, valid driving licence and use of own car.
* Meet DBS standards and Criminal Record checks.
* Understanding of and commitment to equality, diversity and inclusion.
* Ability to competently use technology and IT systems including word processing, email and the internet to create simple personalised plans with individuals.
* Ability to work across multiple sites.
* Provide motivational coaching with the ability to inspire trust and confidence.
* Confident and comfortable with difficult situations.
* Patient, friendly and approachable.
* Able to work under pressure and emotionally resilient.
* Ability to work flexible hours which may include evenings or weekends.
* Ability to actively listen, empathise with people and provide non-judgemental support.
* Ability to respect and value individual lifestyles, backgrounds and cultures.
Qualifications
* Demonstrable commitment to personal and professional development.
* Proficient in the use of Microsoft Office applications.
Experience
* Experience of supporting people, their families and carers in a paid or unpaid capacity.
* Experience of working in a community setting.
* Experience of handling confidential information.
* Experience of collecting and recording information and data.
* Ability to identify risk to self and others, identifying and reporting safeguarding incidents.
* Experience of working in or with voluntary organisations or groups in a paid or unpaid capacity.
* Experience of working collaboratively with different organisations, building trust, confidence and partnerships.
* Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work.
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.
Employer Name
Drake Medical Alliance Primary Care Network
Drake Medical Alliance Limited Operations Manager
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