PCN Care Coordinator

Job responsibilities

Duties and responsibilities

Work with our GPs and other primary care professionals in order to identify and manage a caseload of patients with specific needs, flagging any concerns to the relevant GP and referring to other health and social care professionals as appropriate.

Utilise population health information to identify and work with high-risk patient populations and specific cohorts; such as the frail elderly, those with long term conditions, learning disabilities, those requiring palliative care or safeguarding concerns.

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

Identify those elements of the care plan which require specialist input (pharmacist, dietician, nurse, medic etc) and ensure that these are completed in timely manner.

Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing, providing relevant and up to date information and resources.

Assist with coordinating clinics and recalls for flu, routine immunisations, health checks and other reviews.

Code and log relevant information in EMIS.

Participate in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and Quality Improvement.

Alerts other team members to concerns about risk, quality, and safety.

Participates in investigation of incidents and events as required.

Collects data for audit purposes and supports the use of clinical audit to monitor quality in the service.

Contributes to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.

Effectively manages own time, workload, and resources.

Meets timescales/deadlines for audits and written returns to ensure that the Practice meets quality standards and receives the designated funding.

• To link with and maintain good working relationships with colleagues in Kent County Council, Dartford Borough Council, Imago, Ellenor, HCRG, DGS and ADSS and other partners.
• Supporting practices with other patient groups as required
• Identifying patients with mild to moderate frailty that are living in their own homes.

• Working with patients and our partners, to identify the needs of this group.
• Managing referrals into the monthly Multi-Disciplinary Team meeting and actioning outcomes relating to the practices.

Supporting the Enhanced Health in Care Homes DES.

Supporting practices in maintaining a learning disabilities register and encouraging people on this register to attend the practice for an annual review.

Assisting with the development of personalized care plans, including advanced care plans/treatment escalation plans.

Developing links with organisations involved in the care of this group of patients, including Imago, ADSS, learning disability and community nursing teams and other health and social care partners.

Working with other staff in the practices and PCN to facilitate the early diagnosis of cancer by promoting awareness of signs and symptoms, promoting national cancer screening programmes and ensuring systems are in place for the management and safety netting of suspected cancer investigations and referrals.

Ensuring all patients with a new diagnosis of cancer are coded within the clinical system.

o Inviting patients with a diagnosis of cancer to attend for a cancer care review and ensuring that they are signposted to services provided by partner organisations.

Maintaining palliative care registers within the practice to support practices to deliver end of life care

Developing links with organisations involved in the care of this group of patients, including Ellenor, Cancer Nurse Specialist, Imago, community nursing teams and other health and social care partners.

It is expected that the Care Coordinators will work as a team to provide cross cover for periods of leave.

Confidentiality

• In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

• In the performance of the duties outlined in the Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as business organisation. All such information from any source from any source is to be regarded as strictly confidential.
• Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health & Safety

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety Policy to include:

Using security systems within the workplace according to practice guidelines.

Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks.

Making effective use of training to update knowledge and skills.

Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards and reporting potential risks identified.

Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation.

Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.

Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights.

Personal/Professional Development

The post-holder will participate in training programmes implemented by the PCN as part of this employment, such training to include:

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

• Taking ...