PCN Care Co-ordinator

We are looking for a proactive care coordinator to work on

our Neighbourhood Health and Proactive Care targets within population health

management, focusing on patients with Frailty and Long-Term Conditions.

This will involve working with data, reporting, information

gathering, data analysis, supporting the team with relevant and timely data

streams and organising MDTs for all stakeholders involved in patient care,

providing data required and ensuring the organisation and evaluation minutes

when required of all meetings held. It will also involve engaging with

patients, information assessing and evaluating, and may involve being in the

community talking to patients face to face to support managing their care and

referring within the PCN Integrated Proactive Care Team.

Coding and reporting data from practice systems, data

analysis, cross referencing data streams and delivering data for team members.

Reviewing patient records and collating information for

caseloads in preparation for clinical triage.

Engaging with patients, their families and carers, to

improve their understanding of their condition.

Supporting patients to develop and review personalised care

and support plans to manage their needs and achieve better healthcare outcomes.

Work with patients, their families, carers and healthcare

team members to encourage effective proactive behaviours to avoid reactive care

crisis points.

Support PCNs in developing communication channels between

GPs, patients, their families, carers and other stakeholder agencies.

Help patients 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.

Provide co-ordination and navigation for patients 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 GP practices, other primary and

secondary care professionals, other community stakeholders and the PCN to

proactively identify and manage a caseload, which include patients with frailty

and long-term health conditions where appropriate.

Enable access to personalised care and support

Take referrals or proactively identify patients who could

benefit from support through care co-ordination.

Have positive, empathetic and responsive conversations with

patients and their families and carer(s), about their needs.

Increasing patients understanding of how to manage and

improve health and wellbeing by offering advice and guidance.

Develop an in-depth knowledge of the local health and care

infrastructure and know how and when to enable patients to access support and

services that are right for them.

Use tools to measure patient levels of knowledge, skills and

confidence in managing their health and tailor support to them accordingly.

Support patients to develop and implement personalised care

and support plans.

Review and update personalised care and support plans at

regular intervals.

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.

Co-ordinate and integrate care

Make and manage appointments for patients, related to

primary, secondary, community, local authority, statutory, and voluntary

organisations.

Help patients transition seamlessly between secondary and

community care services, conducting follow-up appointments, and supporting

people to navigate through the wider health and care system.

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.

Regularly liaise with the range of multidisciplinary

professionals and colleagues involved in the persons care, facilitating a

co-ordinated approach and ensuring everyone is kept up to date so that any

issues or concerns can be appropriately addressed and supported.

Actively participate in multidisciplinary team meetings in

the PCN.

Identify when action or additional support is needed,

alerting a named clinical contact in addition to relevant professionals, and

highlighting any safety concerns.

Record what interventions are used to support patients, and

how patients are developing on their health and care journey by providing

evaluations.

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 patients, their families, and carers

to capture key information, while tracking of the impact of care co-ordination

on their health and wellbeing.

Record and collate information according to agreed protocols

and contribute to evaluation reports required for the monitoring and quality

improvement of the service.

3. Supervision/professional development

Undertake continual personal and professional development,

taking an active part in reviewing and developing the role and

responsibilities, and provide evidence of learning activity as required.

Adhere to organisational policies and procedures, including

confidentiality, safeguarding, lone working, information governance, equality,

diversity and inclusion training and health and safety.

Access relevant GPs to discuss patient related concerns, and

be supported to follow appropriate safeguarding procedures

Establish strong working relationships with GPs and practice

teams and PCN clinical team members working collaboratively with other care

organisations and stakeholders, social prescribing link workers and health and

wellbeing coaches, supporting each other, respecting each others views and

meeting daily as a team MDT.

Act as a champion for personalised care and shared decision

making within the PCN.

Demonstrate a flexible attitude and be prepared to carry out

other duties as may be reasonably required from time to time within the general

character of the post or the level of responsibility of the role, ensuring that

work is delivered in a timely and effective manner.

Identify opportunities and gaps in the service and provide

feedback to continually improve the service and contribute to business

planning.

Contribute to the development of policies and plans relating

to equality, diversity, and reduction of health inequalities.

Work in accordance with the practices and PCNs policies and

procedures.

Contribute to the wider aims and objectives of the PCN to

improve and support primary care.

Enable access to personalised care and support

Take referrals or proactively identify people who

could benefit from support through care co-ordination.

Have a positive, empathetic and responsive

conversations with people and their families and carer(s), about their needs.

Increasing patients understanding of how to manage

and improve health and wellbeing by offering advice and guidance.

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.

Use tools to measure peoples levels of knowledge,

skills and confidence in managing their health and tailor support to them

accordingly.

Support people to develop and implement

personalised care and support plans.

Review and update personalised care and support

plans at regular intervals.

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.

Co-ordinate and integrate careMake and manage appointments for patients, related

to primary, secondary, community, local authority, statutory, and voluntary

organisations.

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.

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.

Regularly liaise with the range of

multidisciplinary professionals and colleagues involved in the persons care,

facilitating a co-ordinated approach and ensuring everyone is kept up to date

so that any issues or concerns can be appropriately addressed and supported.

Actively participate in multidisciplinary team

meetings in the PCN.

fIdentify when action or additional support is

needed, alerting a named clinical contact in addition to relevant

professionals, and highlighting any safety concerns.

Record what interventions are used to support

people, and how people are developing on their health and care journey.

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.

Record and collate

information according to agreed protocols and contribute to evaluation reports

required for the monitoring and quality improvement of the service.

3. Supervision/professional development

Undertake continual personal and professional

development, taking an active part in reviewing and developing the role and

responsibilities, and provide evidence of learning activity as required.

Adhere to organisational policies and procedures,

including confidentiality, safeguarding, lone working, information governance,

equality, diversity and inclusion training and health and safety.

Access relevant GPs to discuss patient related

concerns, and be supported to follow appropriate safeguarding procedures

Establish strong working relationships with GPs and

practice teams and work collaboratively with other care co-ordinators, social

prescribing link workers and health and wellbeing coaches, supporting each

other, respecting each others views and meeting regularly as a team.

Act as a champion for personalised care and shared

decision making within the PCN.

cDemonstrate a flexible attitude and be prepared to

carry out other duties as may be reasonably required from time to time within

the general character of the post or the level of responsibility of the role,

ensuring that work is delivered in a timely and effective manner.

Identify opportunities and gaps in the service and

provide feedback to continually improve the service and contribute to business

planning.

Contribute to the development of policies and plans

relating to equality, diversity and reduction of health inequalities.

Work in accordance with the practices and PCNs

policies and procedures.

Contribute to the wider aims and objectives of the

PCN to improve and support primary care.

We are a 6 practice PCN with approximately 65,000 patients. We are rapidly developing our multi-disciplinary workforce, embedding our roles, developing our team that makes a real difference to our patients and our practices. we pride ourselves on tackling the needs of our patients by working together to provide personalised health support for our population health needs.

Morley is a thriving area of South Leeds with a strong community. The area is a highly sought after place to live due to its excellent links to the city and busy town centre.

We would Welcome applicants who have a strong admin and people background.

Experience

Other

Essential: - Access to own transport; - Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social

Qualifications

Essential: - GCSE A-C IN English and Maths; - Meets a Disclosure and Barring Service (DBS) reference standards and criminal record checks

Desirable: - Administration qualifications