PCN Care Coordinator

North Lambeth Primary Care Network are excited to advertise a new role

in our network

As a Care coordinator you will play a crucial role in supporting

patients in preparing for or in following-up clinical conversations they have

with primary care professionals.

You will work closely with the GPs and other primary care professionals

within the PCN to identify and manage a caseload of identified patients, making

sure that appropriate support is made available to them and their carers, and

ensuring that their changing needs are addressed.

You will focus delivery of the comprehensive model to reflect local

priorities, health inequalities or population health management risk

stratification.

2x PCN Care Coordinators wanted at North Lambeth Primary Care Network

Grade/Salary

upto £28K

Hours

37.5

hours per week.

Permanent

Reporting to

North

Lambeth member practices for the Primary Care Network

1.

Undertake

work in line with PCN directed priorities.

2.

Proactively identify and work with a cohort of people to support

their personalised care requirements, using the available decision support aids

3.

regular and consistent communication with the referrer regarding patient

progress and any complications or guidance

4.

Raise awareness of health promotion and NHS health checks in

practices

5.

Work with Member Practices to facilitate the .

6.

Evaluate treatment programmes that promote health and

well-being

7.

Co-ordinate clinics, liaising with the schedulers and

contacting the identified patients with appointments.

8.

Manage patient initiated calls for help/signposting etc,

booking into named GP urgent care slots/tel slots if necessary.

9.

Document and monitor aspects of patient co-ordination and

service delivery, supporting data collection and audit using the patient

administration system

10.

Demonstrate the ability to recognise and respond

appropriately when faced with a sudden deterioration or emergency situation,

alerting the team or enabling a rapid response.

11.

Dependant on work plans, there may be a requirement to work

across different tumour groups and teams.

12.

Organise and prioritise own workload the postholder should

be comfortable working independently and as a committed member of the

multi-disciplinary team.

13.

Support national screening programmes

14.

Support immunisation programmes

15.

Monitor referrals

to ensure tasks are completed and care delivered by keeping in regular

telephone contact

16.

Direct liaison

with multi agencies to coordinate care for patients

17.

social prescribing link workers were a patient is identified as potentially

benefitting from this service

18.

To support

patient/carer contact roles, and collate patient and carer feedback on their

experiences

19.

and Outcome Frameworks and other DES/LES specifications

20.

Maintain and

develop engagement with all practice staff and encourage best practice

21.

Act as the first port of call for patients, in their caseload

in relation to their care.

22.

Bring together all of a persons identified care

and support needs, and explore their options to meet these into a single

personalised care and support plan (PCSP), in line with PCSP best practice

23.

Help people to manage their needs, answering

their queries and supporting them to make appointments

24.

Support people to take up training, employment

and access appropriate benefits where eligible

25.

Raise awareness of shared decision-making and decision

support tools, and assist people to be more prepared to have a shared

decision-making conversation

26.

Ensure that people have good quality information

to help them make choices about their care

27.

Support people to understand their level of knowledge,

skills and confidence their Activation level when engaging with their

health and wellbeing, including using the Patient Activation Measure

28.

Assist people to access self-management education

courses, peer support or interventions that support them in their health and

wellbeing

29.

Explore and assist people to access personal

health budgets where appropriate

30.

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

31.

Support the coordination and delivery of MDTs

within PCNs. - Manage

MDT meetings for this patients and identifying issues to be addressed, liaising

with other agencies if necessary as well as GPs, Pharmacists and Nursing team.

32.

Liaise directly with

Care Homes and other key providers, to identify patients for discussion at MDT,

and compile and circulate relevant information to attendees

33.

Other duties as

defined by the PCN as necessary

North Lambeth Primary Care Network consists of 6 practices (Hurley and

Riverside Practices, Lambeth Walk Group Practice, Mawbey Group Practice,

South Lambeth Road Group Practice, Waterloo Health Centre and the Vauxhall

Surgery) working together to provide excellent patient care to a population of

over 69,000 patients. As a Network we are striving to be at the forefront of

PCN development and are involved in several exciting pilot projects.

Personal Qualities & Attributes

Skills and knowledge

Other

Experience

Qualifications

Desirable: - Training in motivational coaching and interviewing or equivalent