Job summary
The North West PCN Care Coordinator will work solely within a practice setting and with the PCN and Practice Team to support the multi-disciplinary team (MDT) meetings and the ongoing patient case management.
This is an excellent opportunity for someone who enjoys working in a dynamic, fast-paced environment and values face-to-face collaboration.
The role will be working across the GP practice members of the North West PCN.
Main duties of the job
Main duties of the role include:
1. Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
2. Support patients to utilise decision aids in preparation for a shared decision-making conversation
3. Holistically bring together all of a person's 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
4. 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
5. Support people to take up training and employment, and to access appropriate benefits where eligible
6. 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
About us
Primary Care Doncaster (PCD) Ltd is developing a wide range of services to support general practice across the city and is looking at innovative ways to develop its workforce, due to interest by a significant number of GP practices and Networks within the city.
At PCD and within the GP practices and Networks, we believe in the power of collaboration and the creativity that thrives when people work together in person. Each Network has a range of offices and work locations designed to foster innovation, teamwork, and a vibrant work culture where you can grow your career and make a real impact.
As a PCD employee you will have access to the generous NHS Pension Scheme and 27 annual leave days per year.
PCD are an equal opportunities employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.
Job description
Job responsibilities
Further details of the job role include:
7. Explore and assist people to access personal health budgets where appropriate
8. 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
9. Support the coordination and delivery of MDTs within the PCN
10. Support and undertake group consultations and sessions as required
11. Work with the GPs and other primary care professionals within the PCN to identify and Manage a caseload of patients, and where required and as appropriate, refer people back to Other health professionals within the PCN
12. Raise awareness within the PCN of shared-decision making and decision support tools
13. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations
14. To work as a key member of the MDT to help support the development of effective MDT meetings.
15. Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers.
16. To ensure that action points identified within the MDT are recorded and followed up
17. Under guidance from their line manager, take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team
18. To cross reference the patients identified as high risk with the carers register within the practice to support case managers and key workers in developing holistic anticipatory care plans including prevention of carer breakdown
19. To work with the wider MDT to identify appropriate case managers for high risk patients to ensure that patients are reviewed and anticipatory care plans are developed
20. Ensure that all patients Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available
21. To liaise with acute hospitals, cross referencing admission data with the at risk list, and coordinating the sharing of key information between the acute hospital teams and the community services.
22. Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute / community hospital setting
23. Support project management and lead on projects as required
Person Specification
Qualification
Essential
24. NVQ Level 3 or equivalent level of knowledge in office procedures
Experience
Essential
25. Experience of working under own direction
26. Experience in a patient focused environment
27. Evidence of experience in wide range of administrative systems and software programmes
Desirable
28. Experience of supporting service improvement
29. Previous experience in NHS/Primary Care/Local Authority role
Skills and Competencies
Essential
30. Experience of planning and organising complex meetings/agendas
31. Evidence of working with IT systems
32. Evidence of ability to support collation and analysis of data
33. Excellent verbal and written skills
34. Ability to provide and receive complex information
35. Excellent interpersonal skills
Desirable
36. Experience of using a medical software package SystmOne and EMIS Web
37. Proven track record of effective use of networking and influencing skills