Pathways Care Coordinator (East Warrington PCN)

Job responsibilities

Key Responsibilities

Maintain and track a caseload of patients who require support across a variety of medical care pathways

Have a positive, empathetic and responsive conversation with the person, their family and carer(s) about their needs.

For neurodevelopmental pathways, provide support to the individual and practice to ensure documentation and coordination of referral pathways to ensure the patient is accepted for assessment.

Support improvement in cancer screening uptake, liaising with external agencies as appropriate.

Support improvement in recording of blood pressure readings, and supporting improved uptake of NHS Health Checks.

Work closely with Practice Managers, GPs, social prescribers, and other roles in accordance with the medical pathway.

Patient & Family Support

Act as a named point of contact for practices.

Communicate with empathy, when dealing with patients and their carers.

Signpost to local and national support services (e.g. charities, peer groups) and develop a directory of contacts.

Assessment Preparation

Support practices by completion of forms at practice level for any referrals

Support patients and families to complete appropriate referral questionnaires and forms

Liaise with Carers, or other professionals where appropriate

Communication & Liaison

Act as a bridge to other services across Warrington in accordance with patient needs

Build relationships with other services to maintain positive relations on behalf of the PCN.

Act as a bridge between primary care, specialist services, and or under the right to choose pathways

Communicate with empathy for non NHS referrals

Provide updates on referral progress where available

Support patient understanding of the pathway

Record Keeping & Administration

Accurately document patient contacts and interventions in GP clinical systems

Maintain up-to-date records of referrals and outcomes

Support data collection for service evaluation and improvement

Support collection of patient satisfaction questionnaires

Develop a directory of services for the role, maintaining up-to-date information on alternative services in the community and town.

Personal and Professional Development

Keep abreast of national and local guidance on PCNs

Take responsibility for own development, learning and performance.

Participate in an annual individual performance review, and

take responsibility for maintaining a record of own personal and professional development

Support PCN admin and project work

Collaborative Working

Developing and maintaining effective working relationships both within and outside the practice, PCN and locality.

Liaise with other stakeholders as needed for the collective benefit of patients

Assist the PCN to achieve successful multidisciplinary teams (MDTs) across East Neighbourhood (when appropriate)

Other Duties and Responsibilities

As and when required help people to manage their needs through answering queries, making / managing appointments, and ensuring that people have good quality written or verbal information available to them to help them make choices about their care.

As and when required provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, and other primary care professionals; and support the coordination and delivery of MDTs.

Personal Management

Recognise and work within own competence

Prioritise, organise and manage own workload in a manner that maintains and promotes quality.

Demonstrate understanding of the implications of national priorities for the PCN.

Bring to attention of the Practice Manager any clinical incidents, and participate as required in any investigation and learning exercise.

Bring to attention of the Practice Manager any formal complaints, and participate as required in any investigation and subsequent learning exercise.

Education, Training and Development

Participate in relevant training programmes that are consistent with the role.

Maintain a statutory and mandatory training record.

Attend organisational Practice Learning Time Events once a month.

This job description may be reviewed in the light of any national or local policy change and or service needs. Any changes will be fully discussed with the postholder. The post holder may also be required to carry out other work appropriate to the grade of the post.

Location

The successful candidate will be located within GP Practices in East PCN, and travel to and from the GP Practice surgeries and Orford Jubilee hub.

Person Specification

Personal Qualities and attributes

Essential

• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity.
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential.
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community ...