LS25/26 PCN Mental Health Care Coordinator

Support to the Dementia Nurse Service

Work alongside the Dementia Nurse to support patients living with dementia and associated mental health needs.

Support identification and engagement of patients and carers requiring additional support.

Support the development, implementation and review of personalised care and support plans.

Collate and gather relevant information to support clinical discussions and MDT reviews.

Support monitoring of patients awaiting assessment, intervention or ongoing support.

Coordinate multidisciplinary meetings across local care organisations identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.

Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations

Undertake delegated clinical procedures within own skills and competence when required (depending on experience and qualifications)

Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding

Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care

Work with practices to support delivery of any national and local targets with regard to the GP contract e.g. PCN DES

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Care Coordination and Patient Support

Act as a key point of contact for patients, carers and professionals involved in care.

Coordinate care for individuals with complex health, social care and psychological needs.

Support patients to understand their diagnosis, treatment options and available services.

Promote independence, self-management and improved quality of life.

Support patients to attend appointments and engage with health and care services.

Monitor wellbeing and identify changes in need, escalating appropriately.

Support individuals experiencing anxiety, low mood, loneliness, adjustment difficulties or distress.

Provide ongoing contact and support to reduce social isolation and improve engagement.

Carer and Family Support

Provide practical, emotional and informational support to carers and families.

Identify carers experiencing stress, burnout or social isolation.

Support access to carers assessments, respite services, benefits advice and peer support.

Provide information on dementia progression and coping strategies.

Promote carer wellbeing and resilience through ongoing engagement.

Service Navigation and Advocacy

Provide information, advice and signposting to health, social care, housing, welfare and voluntary sector services.

Support patients and carers to access appropriate services and overcome barriers.

Promote personalised care and shared decision-making.

Advocate on behalf of patients and carers where appropriate.

Multi-Disciplinary Team Working

Work collaboratively with GPs, Dementia Nurse, Care Coordinators, Social Prescribers, Community Nurses, Mental Health Practitioners, Social Workers and voluntary sector partners.

Participate in MDT meetings and case discussions as required.

Share relevant information in line with information governance requirements.

Contribute to coordinated, integrated care planning across services.

Safeguarding, Governance and Administration

Identify safeguarding concerns and escalate appropriately in line with procedures.

Support safeguarding processes and contribute to information gathering where required.

Maintain awareness of the Mental Capacity Act and Best Interest decision-making.

Maintain accurate, timely and confidential electronic patient records.

Support audits, data collection and service evaluation activities.

Ensure compliance with GDPR, confidentiality and information governance standards.

Contribute to continuous improvement of the Dementia Nurse Service and Frailty Team.

Attend supervision, mandatory training and team meetings.

Develop and maintain effective working relationships with partner organisations.

Promote equality, diversity, inclusion and person-centred care in all aspects of work.

Work within organisational policies and professional standards.

Undertake any other duties appropriate to the role.

LS25/26 Primary Care Network serves a population of approximately 77,500 patients across seven GP practices. The PCN is committed to delivering high-quality, person-centred care that improves health outcomes, reduces inequalities and supports people with complex health and social care needs to live well within their communities.

Experience

Qualifications

Personal Attributes

Knowledge

Skills and Abilities