PCN Care Co-ordinator

Care Co-ordinators contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions. An ethos of promotion of independence and partnership-working is integral to this post. They 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 Co-ordinators work closely with the GPs and other primary care colleagues within the PCN and within the practices to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers (if appropriate), and ensuring that their changing needs are addressed. They focus on the delivery of personalised care to reflect local PCN priorities, health inequalities or at-risk groups of patients.

A key part of the role of a Care Coordinator role is with the One Team (MDT), improving the continuity of care by acting as a point of contact for, families and professionals, such as MDT members and in-reach specialists.

Multi-Disciplinary

Teams

led MDT meetings and the smooth running of integrated care within the team

setting. A key role of the Care Coordinator is to ensure that all new referrals

are identified, and information circulated to team members in advance of the

meeting.

progress against actions identified in these meetings and ensure follow up

where necessary.

DES specifications for required services.

Patient

Identification.Utilise

population health intelligence to proactively identify and work with a cohort

of patients to deliver personalised care

care (including hospital admissions and discharges) plus out of hours calls and

present this information to the MDT as required.

frequent flyers, and new service users utilising risk stratification tools

provided and present this information to the daily MDT meetings.

criteria, and where criteria have been met, direct referral to the MDT.

relevant services.

Direct

patient facing work

patients identified through the MDT or practice.

decision aids in preparation for a shared decision-making conversation.

all of a persons 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.

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.

training and employment, and to access appropriate benefits where eligible.

their level of knowledge, skills and confidence (their Activation level) when

engaging with their health and well-being, including through the use of the

Patient Activation Measure.

self-management education courses, peer support or interventions that support

them in their health and well-being and increase their activation level.

access personal health budgets where appropriate.

Health Coaches and Village Agents as appropriate.

Communication

and collaborative working relationships

as a member of a team.

limitations and refer to more appropriate colleague(s) when necessary.

developing and maintaining effective working relationships both within and

outside the PCN or group of PCNs.

stakeholders as needed for the collective benefit of patients including but not

limited to Patients GP, Nurses, other practice staff and other healthcare

professionals including pharmacists and pharmacy technicians from provider and

commissioning organisations.

Care Homes to ensure new referrals are logged and allocated.

partners, wider service networks including the voluntary sector, GP practices,

adult social care, hospitals, community pharmacists and other members of the MDT.

carers and professionals who visit the care home, such as MDT members and

in-reach specialists.

case load and MDT function.

news stories.

the daily MDT meetings.

families/carers, and provide coordination across health and care services working

closely with social prescribing link workers, health and well-being coaches, and

other primary care professionals.

deal with the competing demands of the MDT.

Other

to operational priorities.

wider locality areas where necessary.

competency including mandatory training.

environment.

duties and responsibilities with due regard to the GP Practices equal

opportunity policies and procedures.

responsibility for self-development on a continuous basis, undertaking

on-the-job training as required.

responsibilities under the Health and Safety at Work Act, and identify and

report as necessary any untoward accident, incident or potentially hazardous

environment.

Patient

Care

language appropriate to a patient and carer/relatives condition and level of understanding.

aware of and manage barriers to communication.

carers and or relatives

and/or relatives on behalf of the team.

related concerns and be supported to follow appropriate safeguarding procedures

(e.g., abuse, domestic violence and support with mental health) with a relevant

GP.

Supporting

Care Delivery

interface with all health and social care professionals, including keeping

everyone informed and updated.

including arranging tests, referrals, signposting, etc.

involved to ensure all services and care arrangements are in place.

Autonomy/Scope

within Role

clearly defined organisational protocols, policies and procedures.

Key Relationships

Key Working Relationships Internal

for the MDT.

practice teams within the PCN.

Coordinator Team Leader.

including but not exhaustive: Clinical Pharmacists, technicians, District

Nurses, LARCH Team, OPMH, IRT, Adult Social Care, Paramedics, Social

Prescribing Link Workers, Village Agents.

Key Working Relationships External

neighbouring PCNs.

providers.

services.

users.

Health and Safety/Risk Management

all times with the organisation and Practices Health and Safety policies, in

particular by following agreed safe working procedures and reporting incidents

using the organisations Incident Reporting System.

with the Data Protection Act (1984), The General Data Protection Regulations

(2018) and the Access to Health Records Act (1990).

with all necessary training requirements relevant to the role as identified by

the organisation; in particular the post holder must complete the specified

care coordinator training delivered by the Personalised Care Institute.

Equality and Diversity

co-operate with all policies and procedures designed to ensure equality of

employment. Co-workers, patients and visitors must be treated equally

irrespective of gender, ethnic origin, age, disability, sexual orientation,

religion etc.

Respect for Patient

Confidentiality

respect patient confidentiality and not divulge patient information unless

sanctioned by the requirements of the role.

Special Working Conditions

travel independently between practice sites (where applicable), and to attend

meetings etc. hosted by other agencies.

North Sedgemoor PCN brings together GP practices caring for around 50,000 people across Burnham on Sea, Brent, Highbridge, Cheddar and Axbridge. We are clinically led, collaborative and community focused. Our team includes GPs, Occupational Therapists, Pharmacists, Care Coordinators, Health Coaches, Paramedics, Digital & Transformation Leads and Service Leads.

We are a learning organisation. You will have a named supervisor. We value curiosity, high standards and kindness. Ideas are welcomed and improvement is part of daily work.

This is an exciting time to join us. We are scaling services and modernising how we deliver urgent and planned care in practices, in peoples homes and in care homes. You will be supported by clear pathways, friendly colleagues and a welcome team who help new colleagues settle in.

You will receive an NHS pension if eligible, generous annual leave and access to well-being resources.

Qualifications

Experience

Values, Drivers and Motivators

Aptitude and Personal Qualities