PCN Care Coordinator

Multi-Disciplinary Teams Overall responsibility for arranging the daily and weekly PCN and Community team led MDT meetings to ensure smooth running of integrated care within the team setting. Key roles include searches and discharge data analysis to identify patients, managing the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members of the meeting as required. Coordinate and manage the administrative functions of MDT meetings. 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. Manage reporting required and associated within the DES specifications for required services. Patient Identification Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required. Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the weekly MDT meetings. Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT. Signpost team members, service users and carers to relevant services Maintenance of IT based information systems and responsibility for key performance data: To ensure the IT requirements for recording activity are adhered to in collaboration with other team members Accurate update and maintenance of GP systems within the MDT. To provide agreed performance/activity data within the MDT and PCN. Communication and collaborative working relationships Demonstrates ability to work as a member of a team. Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary. Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs. Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations. Work with service users, PCN practices and partners Develop excellent working relationships with all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT Acting as a point of contact for residents, families and professionals who visit the care home, such as MDT members and in-reach specialists. Meet regularly with the clinical lead and review case load and MDT function. Keep the MDT and OHP organisation abreast of good news stories. Provide background information about individuals for the weekly MDT meetings Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT Helping support delivery of PCN services To support the PCN delivery of relevant services to the patient population including but not limited to the following services: Tackling Neighbourhood Health Inequalities, Personalised Care and Anticipatory Care Undertake basic health care assistant roles such as phlebotomy, simple clinical assessment and support patients as a link worker. Training will be provided to obtain this skill set if needed. Other responsibilities To act at all times in an anti-discriminatory manner To be able to plan and respond to workload according to operational priorities To support the delivery of these functions across wider locality areas where necessary To undertake any training required in order to maintain competency including mandatory training To contribute to, and work within a safe working environment. The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment. Patient Care 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 Supporting Care Delivery Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc. Follow through with service users and others involved to ensure all services and care arrangements are in place Autonomy/Scope within Role The post holder will be required to work within clearly defined organisational protocols, policies and procedures

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