As a PCN Care Coordinator, you will be part of the Primary Care Multidisciplinary Team, offering a personalised Admin approach to caring for the social and psychological needs of identified patients on your caseload, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
You will work closely with the GPs and other members of the practice and PCN teams to ensure the Admin coordination and management of identified patients at all points of their care journey.
Main duties of the job
* Create a positive working environment in which equality and diversity are professionally managed, dignity at work is upheld, and staff can do their best;
* Work alongside other ARRS roles to effectively perform the role and develop throughout by attending supervision sessions, appraisal meetings, and training / development days.
* Ensure that Standard Operating Procedures (SOPs) are adhered to supporting the delivery of service and completing reviews and updates with the PCN management team.
* Utilise an adequate level of knowledge around primary care to meet the required needs of the service.
* Support the other ARRS staff/PCN management team to develop the quality of work and keep detailed records of day-to-day tasks including managing caseloads.
* Encourage good teamwork throughout the partnership and with each of the GP surgeries and contributing to the Enhanced Health for Care home.
About us
We are a Primary Care Network ( PCN ) of six practices working together with a range of local providers, including primary care, community services, social care, and the voluntary sector, to offer more personalized, coordinated health and social care to their local populations.
Our PCN comprises of 49,348 patients over the six practices.
Job responsibilities
As a PCN Care Coordinator, you will work closely with member practices and the PCN in offering a personalised approach to caring for social and psychological needs of identified patients on your caseload, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
Your main duties will include:
* 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;
* Utilising population health intelligence to proactively identify and work with a cohort of patients to deliver a personalised care approach;
* Facilitating and ensuring the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames;
* Providing coordination and navigation for patients and their carers across the spectrum of services available;
* Supporting local Care Homes to manage patient needs, including completing/reviewing Care Home Care Plans and Dementia reviews as required, contributing to Care home ward rounds;
* Completing Annual Learning Disability reviews on behalf of the practice;
* Assisting clinicians who visit patients in their own homes, where applicable, for Blood Pressure checks, welfare checks, and providing support;
* Working alongside other PCN Additional Roles staff and outside agencies to provide wrap-around support to patients;
* 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
Experience
* Ability to manage and prioritise a caseload.
* Ability to work flexibly and enthusiastically within a team or on own initiative.
* Good communication skills, both written and verbal.
* Ability to build relationships with patients, their families, and carers.
* Ability to provide personalised support to individuals, their families, and carers.
* Ability to listen and empathise with people in a non-judgmental way.
* Able to provide leadership and complete tasks in a timely manner.
* Able to maintain effective working relationships and promote collaborative working.
* Ability to communicate difficult messages to patients and families.
* Experience of using clinical systems such as EMIS Web.
Qualifications
* GCSE Grade C or above in Maths and English, or equivalent qualification.
* NVQ Level 3, Advanced Level or equivalent or working towards and a commitment to professional and personal development.
Personal Qualities
* Full UK driving licence and access to a car.
* The post-holder is required to travel independently between practice sites (where applicable) and to attend meetings hosted by other agencies.
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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