Pcn Care Coordinator

Pendle West PCN is looking for a Care Co-ordinator to join our growing team.

This is an exciting opportunity to help deliver integrated care based around the needs of our patient population.

Working very closely with the practice and multidisciplinary team (MDT) within the PCN these roles are pivotal in ensuring all patients receive the best possible care and service.

The role will suit individuals with a strong administrative, HCA, OT or similar background.

We have several posts available working with specific cohorts of patients or projects e.g. care homes, cancer, diabetes, health and wellbeing.

Hours are negotiable between 30-37.5 per week.

Applicants need to be flexible to work across our geographical area of Nelson and Brierfield.

General practice experience is desirable but not essential.

Main duties of the job

Our aim is to ensure our patients feel supported and have access to the services that are right for them, helping them to manage their own needs where possible, promote and encourage patient awareness, skills and confidence and to help patients maintain and make decisions about their own health and wellbeing.

There will be a focus on those patients who are harder to reach or may have access or unmet needs.

About us

Pendle West PCN is made up of seven GP practices within Nelson and Brierfield and covers a local population of circa 52,000.

The PCN has a strong commitment to leading and developing change in the local healthcare community.

We have a vision for healthcare that is sustainable, high quality and offers excellent patient and staff experience.

Our services are designed to reflect the needs of the population they serve, and promote lifestyle health and wellbeing.

We offer development and training supported by a full complement of experienced clinical support staff, non-clinical support staff and management.

Primary care networks build on the core of current primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care.

We are committed to working together to improve the health and wellbeing of local people.

Job responsibilities

Pendle West PCN

PCN Care Co-ordinator - Job Description

Responsible to -

Clinical Director

Accountable to -

Pendle West PCN Board

Hours of work -

30+

Salary -

Equivalent to Band 4 Agenda for Change

Job Summary

To provide co-ordination and navigation for people and their carers across health and care services, working closely with Social Prescribing Link Workers, Health and Wellbeing Coaches and a range of primary care professionals within Pendle West Primary Care Network (PCN).

The Care Co-ordinator will be a member of the PCN Multidisciplinary Team (MDT) and will be responsible for co-ordinating and facilitating elements of care for people registered with our 7 local GP Practices to improve the quality of care and support they receive.

The Care Co-ordinator will support the co-ordination and delivery of MDT meetings within the PCN.

A key part of the role is also to provide organisational and administrative support to the neighbourhood team.

As this is a new role the duties of this post will be subject to review regularly.

Primary Duties and Areas of Responsibility

To work closely and in partnership with the GP practices and health and wellbeing team within the PCN.

To utilise local population health information to proactively identify and work with a cohort of patients to deliver personalised care.

To support patients to utilise decision aids in preparation for a shared decision-making conversation.

To holistically bring together all of a persons identified care and support needs, and explore the options to meet these, within a single personalised care and support plan (PCSP), in line with best practice and based on what matters to the person.

To help people to manage their 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.

To support people to take up training and employment, and to access appropriate benefits where eligible.

To support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their personal health and wellbeing, including through the use of the Patient Activation Measure or another suitable assessment tool.

To assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.

To provide co-ordination and navigation for people and their carers across health and care services, working closely with Social Prescribing Link Workers, Health and Wellbeing Coaches, and other primary care professionals, and support the co-ordination and delivery of MDTs within the PCN.

To work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN.

To raise awareness within the PCN of shared-decision making and decision support tools; and how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.

To be able to plan and respond to workload according to operational priorities.

More specifically, in relation to arranging the MDT meetings, the postholder will be required :

To schedule the monthly MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.

To co-ordinate and manage the administrative functions of MDT meetings.

To liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.

Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.

Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.

Manage reporting required and associated within the Network DES specifications for required services.

Communicate effectively and sensitively and use language appropriate to a patient and carer / relatives condition and level of understanding.

Effectively use all methods of communication and be aware of and manage barriers to communication.

Effectively recognise and manage challenging behaviours, carers and or relatives.

Provide information to patients, their carers and / or relatives on behalf of the team.

Health and Safety / Risk Management

The post holder must comply at all times with the organisation and PCN Practices Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System.

The post holder will comply with the Data Protection Act (1984), The General Data Protection Regulations (2018) and the Access to Health Records Act (1990).

The post holder will comply with all necessary training requirements relevant to the role as identified by the PCN.

Equality and Diversity

The post holder must 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

The post holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.

Personal / Professional Development

The postholder will participate in any training programme implemented by the PCN as part of this employment, such as training to include :

o All statutory and mandatory training requirements.

o Participation in an annual performance review, including taking responsibility for maintaining a record of own personal and / or professional development.

o Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

Communication

The postholder should recognise the importance of effective communication within the team and will strive to :

o Communicate effectively with other team members.

o Communicate effectively with patients and their carers.

Safeguarding

The postholder is required to undertake regular safeguarding training and to report any concerns wither to the PCN Clinical Director or to the respective Practice Safeguarding Leads.

Special Working Conditions

The post holder is required to travel independently between local sites when necessary.

Job Description Agreement

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.

Person Specification

Aptitude and Personal Qualities

Professional attitude and assertive approach

Committed to development

Conscientious, hardworking and self-motivated to work with minimal supervision

Creative and tenacious in finding solutions to difficult problems

Ability to meet deadlines and work under pressure

Ability to engage and sustain relationships with all professionals, other organisations and service-users

Approachable and flexible

Honest and reliable

Sensitive to patients needs

Demonstrate commitment to combatting disadvantage and inequality in health provision

Commitment to person centred care

Demonstrate a willingness to participate in sharing the future of the PCN by taking on responsibilities and projects in addition to core workload

Forward thinker

Able to work in a changing environment

Values, Drivers and Motivators

Willingness to undergo further training and development

Requires a flexible approach and a need to be highly motivated

The role may need to be reviewed and developed in the future in line with changing priorities

Other

Flexibility to work outside of core office hours if required

Car user (to travel between more than one GP practice and other sites within the PCN geographical footprint)

Car insured for business use

Qualifications

Educated to GCSE or equivalent

Evidence of further study / training

GSCE Grade C (or equivalent) in Maths and English

Skills and Attributes

Excellent written and verbal communication skills

Excellent interpersonal skills

Excellent knowledge of Microsoft Office

Able to deal with service users sensitively

Able to work as part of a team

Ability to work independently and prioritise own workload working on complex cases in a busy environment

Ability to work as a member of a multidisciplinary team

Excellent motivational and influencing skills

Strong analytical and judgement skills

Ability to analyse and interpret information and present results in a clear and concise manner

Excellent organisational and administration skills

Ensures completion of tasks on time and able to effectively influence others to complete agreed actions

Experience of providing advice / signposting to users

Experience

Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality

Understanding of social determinants of health and how these can be addressed in regard to patient care

Sound understanding of disease prevention (primary, secondary and tertiary) and how patients can build prevention into their lifestyle

Minimum of 2 years experience of working with healthcare professionals and / or previous experience in the NHS or social care or relevant field

Experience of electronic patients records

Experience of working in a patient facing role

Experience of setting up meetings through Microsoft Teams or Zoom

Experience of data collection and providing monitoring information

Experience of working in a multidisciplinary setting where influence and negotiation is required

Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes

Experience of undertaking quality improvement activity

Awareness of local services and resources for individuals, carers and families

Knowledge / familiarity of medical terminology

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Full-time,Part-time,Job share,Flexible working

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