PCN Primary Care Coordinator
Job Description
Job summary
An excellent opportunity has arisen for a Care Coordinator to join our Primary Care Network. A Care Coordinator works with patients, devising and organising personalised care plans, enabling patients to access health, social care and wellbeing services, professionals and information tailored to their individual needs.
Main duties of the job
The Care Coordinator holds a case-load of patients, guiding each patient through the various pathways and processes, facilitating actions and liaising as required.
The Care Coordinator is a key part of the PCN Primary Care Team, working in tandem with the GPs, the nursing, administrative/ reception and pharmacy teams and linking with partner services such as the Integrated Care Team and Physiotherapists.
About us
The Hayling Island & Emsworth Primary Care Network (PCN) is formed of three GP practices, The Elms Practice, Waterside Medical Practice and Emsworth Surgery. It serves a population of 30,000 people across the two communities of Hayling Island and Emsworth.
The PCN aims to provide primary care of the highest quality, safety and value and improve the health and wellbeing of its population by working at individual practice level, collaboratively at PCN level and in partnership with external health, social care and community providers.
Job responsibilities
- Main Duties and Responsibilities
Duties may be varied from time to time under the direction of the Operation Manager dependent on current and evolving Practice workload and staffing levels:
-Working with the primary care team, identify cohorts of patients for whom personalised care plans would be beneficial.
-Contact and work with these patients to develop agreed, tailored care and support plans
-Check and ensure each patient understands and considers the options and choices available to them for each element of their care plan.
-Source and provide patients with relevant and appropriate information to support shared decision making.
-Collate the agreed care and support needs into a personalised care plan in line with best practice and upload and regularly update the plan on the patient record.
-Assist the patient to navigate and progress through the relevant pathways, processes and systems; answering patient questions, making phone-calls, appointments, arrangements for care, liaising with professionals, service personnel and wider stakeholders.
-Work with the multidisciplinary practice team to design and implement new pathways for effective follow-up of patients with Long Term Conditions.
-Implement a process for safety-netting at the practice, so patients are followed up effectively. For example: patients with early signs of possible cancer, those with monitoring blood tests (eg PSA), on regular injections (eg Denosumab, Prostap) and others with more bespoke follow-up needs.
-Assist the patient to access self-education, personalised budgets advice, employment advice, befriending and community activities support and resources to meet their wellbeing needs
-Liaise with health and social care professionals to progress plans and follow-up on any
-Identified barriers, taking action to resolve them. Where barriers persist, discuss with relevant professional to determine action
-Work in a safe and organised manner
-Work with the other PCN Care Coordinators to share learning and best practice
-Provide cross-cover for the other care coordinators within the PCN Team at times of annual leave and sickness
-Work with and assist our secretaries with cases which require coordination eg advice and guidance, GDPR. Some cross-cover may be required
-Build and maintain effective relationships with members of the Primary Care Teams, The PCN community services, Social Prescribing and Wellbeing Coaches, ICS Coordinator
-Participate in MDT meetings, Practice and PCN Meetings
-Observe and comply with appropriate statutory requirements in relation to Child and Adult Safeguarding and to be familiar with the reporting process could this be required.
-Undertake mandatory training
-Comply with Data Protection and Information Governance regulations and policies
OTHER DUTIES:
2. 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 this 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 a business organisation. All such information 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.
3. 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, the practice Health & Safety Manual, and the practice Infection Control Policy and published procedures. This will include:
-Using personal 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
-Actively reporting of health and safety hazards and infection hazards immediately when recognised
-Keeping own work areas and general / patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holder's role
-Undertaking periodic infection control training via e-learning modules
-Reporting potential risks identified to key personnel
4. 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 people's 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-judgmental and respects their circumstances, feelings priorities and rights.
5. Personal/Professional Development:
The post-holder will participate in any training programme implemented by the Practice as part of this employment, such training to include:
-Participation in an individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
-Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work
-Working with clinicians in stages when working out templates for the Quick Message system and or training.
6. Quality:
The post-holder will strive to maintain quality within the Practice, and will:
-Alert other team members to issues of quality and risk
-Assess own performance and take accountability for own actions, either directly or under supervision
-Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team's performance
-Work effectively with individuals in other agencies to meet patients' needs
-Effectively manage own time, workload and resources
7. Communication:
The post-holder should recognise the importance of effective communication within the team and will strive to:
-Communicate effectively with other team members
-Communicate effectively with patients and carers
-Recognise people's needs for alternative methods of communication and respond accordingly
8. Contribution to the Implementation of Services:
The post-holder will:
-Apply Practice and PCN policies, standards and guidance
-Discuss with other members of the team how the policies, standards and guidelines will affect own work
-Participate in audit where appropriate
-Assist the PCN to deliver on the requirements of the PCN DES Contract, quality initiatives, public health initiatives
Person Specification
Qualifications
Essential
- Good level of education to GCSE standard or equivalent
Experience
Essential
- Experience of working in a patient facing role in primary care or health care setting
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