PCN - Care Coordinator

Work within

our network of GP Practices to provide a central co-ordination role for patient

care planning. The role will be GP facing, with the core responsibility being

excellent patient care.

You will be expected to take part in MDT meetings with GP and Nurse and present.

care packages for patients as identified by the GP across health, social care

and mental health as appropriate, providing a single-point of access for staff

& service users, actively managing patients care plan delivery

smooth and planned discharge and handover between care settings across the

health and social care system, including GP, acute, community, and be

responsible for facilitating inter-agency communication and support

and work with a list of named patients with the aim of encouraging

independence, enabling people to remain at home, reducing unnecessary

admissions to hospitals and supporting early discharge from hospital, improving

the quality of care.

1.

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

2.

Explain the management of a patients pathway to clinical staff,

liaising between services and service users, contacting services using the

appropriate procedures/referral mechanisms

3.

closely with all relevant care agencies (primary care, secondary care, community

services, Mental Health, Social Services, Ambulance Service, Voluntary services

and other relevant service providers) to ensure a coordinated and of the

patients care plan, without requiring a further referral from the GP.

4.

Maintain accurate records and statistical returns as required by

the CCG, including providing patient-related information for entering into

Clinical Reporting Systems, within the required time frame.

5.

Ensure that a proper handover of care between different settings

has taken place, including mutual transfer of all organisations communications

& patient notes and ensuring care packages are set up

6.

Collect data on patients/carers for recognised outcome measure and

document for service interpretation. Ensure all patient notes are updated to

reflect any changes, including details on plans

7.

Managing operational meeting processes, identifying patients for

discussion and working closely with clinicians to define and lead the meetings.

Organise and attend relevant meetings when required including Integrated Care

meetings, ensure a programme of regular meetings is established, ensuring that

all necessary documentation is circulated in advance

8.

Ensure that meeting actions are recorded, disseminated and

followed up in a timely way; ensure relevant practitioners are aware of meeting

decisions and actions / outcomes, and chase for action resolution and update.

9.

Network and develop strong relationships with all levels of the

NHSs key local players including the CCG, GPs and other primary care

contractors, Social Services, Mental Health Trusts, Community Trusts, and other

providers including the voluntary sector

10. Present in MDT meetings with GP and Nurse

Be a contact point for GPs / practices and establish systems and

processes which will ensure a timely and appropriate response to queries from

clinicians and other stakeholders

WF GP FedNet is a not-for-profit Federation of 36 GP Practices in Waltham Forest. We are a private limited company who provides NHS Services based in Primary Care, pooling the skills and resources of local GPs to provide large scale services as part of the local NHS Strategy to bring more services into the Community to help people stay well and at home

Qualifications

Desirable: - Qualification in health or social care allied profession