Care Co-ordinator

As a PCN Care Coordinator you will

work closely with teams to help and support the multi-disciplinary team (MDT)

meetings offering a personalised care approach, and the ongoing patient case

management making sure that appropriate

support is made available to them and their carers, and ensuring that their

changing needs are addressed. This will involve linking with GP

surgeries and a range of Community Health Services and VCSF services.

work closely with the GPs and other

members of your assigned practice(s) and PCN teams to ensure the coordination

and management of identified patients at all points of their care journey.

assist

with the co-ordination of Network clinics, services and projects

liaise

with the additional roles staff in the PCN to meet any unmet patient needs, for

example Social Prescribing Link Worker

Deliver against a thematic area of the

PCN work

Responsibilities;

Utilise population health intelligence to proactively identify and

work with a cohort of patients to deliver personalised care

Undertake practice work in line with PCN directed priorities.

Proactively identify and work with a cohort of practice patients

to support their personalised care requirements

Raise awareness of health promotion and NHS health checks in your

allocated practice

Support uptake of national screening programmes

Support immunisation programmes

Support the practice with IIF targets

Support the practice in inequalities for safer surgeries

Direct liaison with multi agencies to coordinate care for patients

Refer to PCN social prescribing link workers as appropriate

Support Quality and Outcome Frameworks and other DES/LES

specifications

Maintain and develop engagement with all practice staff and

encourage best practice

Support the practice with Learning disabilities and Cancer patient

targets

Provide coordination and navigation for people and their carers

across health and care services, alongside working closely with social

prescribing link workers and other primary care roles

Assist people to access self-management education courses, peer

support or interventions that support

them in their

health and wellbeing.

Support the

coordination and delivery of MDTs within PCNs.

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

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

To

work as a key member of the MDT to help support the development of effective

MDT meetings.

Act

as a contact to practices to assist with case management of patients at risk of

admission, identifying sources of support in liaison with case managers.

To

ensure that action points identified within the MDT are recorded and followed

up

Under

guidance from their line manager, take initiative in the organisation and

administration of MDT working to minimise the demands upon the

multidisciplinary team

work with the wider MDT to identify at risk patients and ensure these patients

are reviewed and anticipatory care plans are developed.

review 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

support PCN projects and collate patient and carer feedback on their

experiences

people to manage their needs, answering their queries and supporting them to

make appointments

Support line management by collating your allocated practices data and

providing a monthly board report.

Support line management by collating your allocated practices data and

providing a monthly board report.

iGPc is a Primary Care Network of 8 GP practices within Liverpool, with a patient population of approximately 62,000.

The collaboration of our member GP Practices is designed to address the healthcare needs of the local community by making full use of the resources and hands on experience of our Practices, as well as other healthcare providers and partners.

iGPc recognises the unique position that it holds as a group of GP Practices within the community and the opportunity that this gives to shape the provision of health and wider services to the local population.

Qualifications

Essential: - NVQ Level 3 or equivalent level of knowledge in office procedures; - Evidence of commitment to continuing professional development

Desirable: - ECDL or equivalent

Other

Experience

Knowledge and Skills