PCN Care Coordinator

Responsibilities include but are not limited to the following:

To work closely with the INT Leads, PCN Manager in supporting the Clinical Director, PCN practices and team in delivering the PCN Contract DES Specifications. The successful candidate will need to understand the importance of engaging with external agencies within our area in order for our service users to achieve high-quality care that we in Navigo always strive to deliver. This should involve using supervision and reflecting on practice to develop new and improved ways of working.

Undertaking a wide range of administrative duties and providing administrative support to the Primary Care Network and team, including arranging MDT meetings, minute taking and recording.

Assisting the INT leads & PCN Manager with their relationships and engagement with the PCN practices and other stakeholders across the locality to ensure a collaborative approach to service development and delivery.

Build and maintain PCN clinics on Systmone along with booking and cancelling patient appointments.

Utilising population health intelligence to proactively identify and work with cohorts of patients across the PCN

Have a proactive approach, the ability to work on your own initiative and within a team environment.

This role will require the post holder to be based at Jubilee Gardens Medical centre and have the ability to visit PCN practices if and when required.

Asa PCN Care Coordinator, you will work closely with member practices and the PCN in offering a personalised approach to caring for social and psychological needs of identified patients on your caseload, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.

You will also support other ARRS roles by contributing towards projects on an ad hoc basis to support health improvements to patients registered with member practices.

Your main duties will include

Receiving and actioning referrals from a wide range of agencies, working with GP practices within the Primary Care Network (PCN), pharmacies, multi-disciplinary teams, hospital discharge teams and allied health professionals (list not exhaustive);

To support the PCN in the delivery of the DES specifications, such as tackling health inequalities through targeted work with specific groups identified through population health management.

To support the coordination and delivery of MDTs within the PCN

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care approach;

Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames;

Provide coordination and navigation for patients and their carers across the spectrum of services available;

Work alongside other PCN Additional Roles staff and outside agencies to provide wrap-around support to patients;

Make appropriate third-party referrals; andComplete and maintain accurate patient records.

This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to consider development within the practices. The post holder should be prepared to take on additional duties or relinquish existing duties to maintain the efficient running of the Network. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.

The roles involves travelling to PCN member practices as required for the service delivery.

Northolt Primary Care Network started in the year 2019. We have 6 GP practices in the PCN. You will be working with 1 or more practices within the PCN.

You will be reporting to the INT leads, PCN Manager and PCN clinical Director. Your Day to day clinical & non clinical supervision is received from staff you will be reporting to as mentioned above.

We aim to Provide high quality accessible primary medical care. To follow up to date guidelines for best clinical practice. To ensure and support continued professional development of the Primary Health Care Team To provide an open, safe and pleasant environment for staff and patients alike To treat all patients in a polite, fair and equitable manner.

Qualifications

Experience

Additional Criteria