PCN Care Co-ordinator

Job responsibilities

Multi-Disciplinary Teams

• Overall responsibility for arranging the daily PCN led MDT meetings and the smooth running of integrated care within the team setting. A key role of the Care Coordinator is to ensure that all new referrals are identified, and information circulated to team members in advance of the meeting.
• Take notes 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 NHSE DES specifications for required services.

Patient Identification. Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care

• 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 daily 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.

Direct patient facing work

• Support with the administration and patient management of the Community Investigation Hub, which provides a number of medical services for our patients within our neighbourhood.
• Manage a caseload of patients identified through the MDT or practice.
• Support patients to utilise decision aids in preparation for a shared decision-making conversation.
• 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.
• 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.
• Support people to take up training and employment, and to access appropriate benefits where eligible.
• Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and well-being, including through the use of the Patient Activation Measure.
• Assist people to access self-management education courses, peer support or interventions that support them in their health and well-being and increase their activation level.
• Explore and assist people to access personal health budgets where appropriate.
• Refer or liaise with the Health Coaches and Village Agents as appropriate.

Communication and collaborative working relationships

• Demonstrate ability to work as a member of a team.
• Can 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 e.g., Care Homes to ensure new referrals are logged and allocated.
• 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.
• Act as a point of contact for residents, families, carers 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 daily MDT meetings.
• Communicate effectively with service users and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and well-being coaches, and other primary care professionals.
• Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT.

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 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.
• The PCN will ensure the PCNs Care Coordinator can discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g., abuse, domestic violence and support with mental health) with a relevant GP.

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.
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