About this role
Job summary
Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
Care Coordinators work closely with GPs and practice teams to manage patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers.
We are seeking an experienced, self-motivated, hard-working, and patient focused Care Coordinator to join our PCN. They will work closely with the GPs and other primary care professionals within the PCN to proactively identify and manage a caseload of patients, making sure that holistic support and is made available to them and that their complex needs are addressed. They may also be asked to contribute towards other administrate tasks within the GP Practice or PCN.
Main duties of the job
The successful candidate will be based in our PCN Hub at The Woodberry Practice. They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a growing team and committed to providing the PCN, practices, patients, their families and carers with high quality support.
Supporting PCN practices with Health Action PlanningHelp 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.Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.Support PCN practices with the call and recall of immunisationsSupporting PCN practices to book clinicsSupporting the PCN with the Extended Access Clinics (uploading and amending clinics to the clinical system)Collating CONSENT formsLiaison with the PCN manager for ad-hoc PCN dutiesSupporting PCN practices with the delivery of QOFSupporting the PCN with delivery of the Impact and Investment Fund
About us
The Enfield South West Primary Care Network (PCN) has a combined geographic area covering South West Enfield. There is a wide socio-economic and demographic served within this area, which will provide an interesting and varied case mix.
This is an exciting opportunity to be an important member of highly motivated teams of clinicians ( GPs , Pharmacists, First Contact Physiotherapist, Paramedic, Practice Nurses, Healthcare Assistants and Social Prescriber) backed up by strong administrative teams.
We pride ourselves in providing the best care for our patients and offering mentorship/ development support for those who work with us.
Equally, we would expect you to be passionate about developing a career in Primary Care and helping us to shape our services.
Job description Job responsibilities
Key responsibilities
Work with people, their families and carers, to improve their understanding of their condition. Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health. Provide co-ordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN. Support the co-ordination and delivery of multidisciplinary teams with the PCN. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations. Explore and assist people to access a personal health budget where appropriate. Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours. Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies. Identify carers and help them access services to support them. Conduct follow-ups on communications from out of hospital and in-patient services. Maintain records of referrals and interventions to enable monitoring and evaluation of the service. Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances. Contribute to risk and impact assessments, monitoring and evaluations of the service. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care co-ordination on their health and wellbeing.
Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives.Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
1. Enable access to personalised care and support
a. Take referrals or proactively identify people who could benefit from support through care co-ordination.
b. Have a positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
c. Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance.
d. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them.
e. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.
f. Support people to develop and implement personalised care and support plans.
g. Review and update personalised care and support plans at regular intervals.
h. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
i. Where a personal health budget is an option, work with the person and the local ICS team to provide advice and support as appropriate.
2. Co-ordinate and integrate care
a. Make and manage appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
b. 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.
c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.
d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons 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.
e. Actively participate in multidisciplinary team meetings in the PCN.
f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
g. Record what interventions are used to support people, and how people are developing on their health and care journey.
Please note this list of duties is not exhaustive.
Person Specification
Qualifications Essential
Educated to GCSE or Equivalent (A-C) Experience with using the clinical system - EMIS An interest in primary care
Experience Essential
Experience working in general practice
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 details Employer name Woodberry Practice
Address The Woodberry Practice
1 Woodberry Avenue
London
N21 3LE
United Kingdom
Employer's website http://www.thewoodberrypractice.com/ (Opens in a new tab)