PCN Care Co-ordinator

NHS; Leeds; On-site; GBP 20,000 - 30,000; Full time

Job summary

A healthcare provider in Leeds is seeking an experienced care co-ordinator to manage patient support and develop personalised care plans. The ideal candidate will collaborate with GPs and healthcare teams to ensure optimal care is provided to populations with long-term health conditions. Applicants must have experience in care coordination and a strong understanding of the health and social care landscape, alongside essential communication skills. A GCSE in English and Maths is required for this vital role.

Qualifications

• Experience in a care co-ordinator role or similar.
• Familiarity with healthcare and social care settings.
• Capable of working within multi-professional teams.

Responsibilities

• Support patients and families in managing care.
• Develop and review personalised care plans.
• Coordinate care among health professionals.

Skills

Experience in care coordination

Understanding of long-term conditions

Strong interpersonal skills

Ability to create personalised care plans

Education

GCSE A-C in English and Maths

Tools

System 1

Job description

Morley and District Primary Care Network have an exciting opportunity for an experienced care co-ordinator to join their team.

This is a important role that will help shape and form the layout of our local healthcare offer in Morley, Leeds.

The suitable candidate should be passionate about making a difference in primary care and enjoy working as part of a multi-disciplinary team across services.

Care co-ordinators play an important role within a PCN toproactively identify and work with people, including the frail/elderly andthose with long-term conditions, to provide co-ordination and navigation ofcare and support across health and care services.

They work closely with GPs and practice teams to manage acaseload of patients, acting as a central point of contact to ensureappropriate support is made available to people and their carers; supportingthem to understand and manage their condition and ensuring their changing needsare addressed.

This is achieved by bringing together all the informationabout a persons identified care and support needs and exploring options tomeet these within a single personalised care and support plan, based on whatmatters to the person.

Care co-ordinators could provide time, capacity andexpertise to support people in preparing for, or following-up, clinicalconversations. Enabling them to be more actively involved in managing theircare and supporting them to make choices that are right for them.

Main duties of the job

We are looking for a care coordinator to work on our population health management needs, this may involve been in the community talking to patients and managing their care.

Keyresponsibilities

Work with people,their families and carers, to improve their understanding of their condition.

Support people to develop andreview personalised care and support plans to manage their needs and achievebetter healthcare outcomes.

Work with people,their families, carers and healthcare team members to encourage effectivehelp-seeking behaviours.

Support PCNs indeveloping communication channels between GPs, people and their families andcarers and other agencies.

Help people tomanage their needs by providing a contact to answer queries, make and manageappointments, and ensure that people have good quality written or verbalinformation to help them make choices about their care.

Provide co-ordinationand navigation for people and their carers across health and care services. Helpingto ensure patients receive a joined-up service and the appropriate support fromthe right person at the right time.

Workcollaboratively with GPs and other primary care professionals within the PCN toproactively identify and manage a caseload, which may include patients withlong-term health conditions, and where appropriate, refer back to other healthprofessionals within the PCN.

About us

We are a 6 practice PCN with approximately 65,000 patients. We are rapidly developing our multi-disciplinary workforce, embedding our roles, developing our team that makes a real difference to our patients and our practices. we pride ourselves on tackling the needs of our patients by working together to provide personalised health support for our population health needs.

Morley is a thriving area of South Leeds with a strong community. The area is a highly sought after place to live due to its excellent links to the city and busy town centre.

We would Welcome applicants who have a strong admin and people background.

Job responsibilities

Enable access to personalised care and support

Take referrals or proactively identify people whocould benefit from support through care co-ordination.

Have a positive, empathetic and responsiveconversations with people and their families and carer(s), about their needs.

Increasing patients understanding of how to manageand improve health and wellbeing by offering advice and guidance.

Develop an in-depth knowledge of the local healthand care infrastructure and know how and when to enable people to accesssupport and services that are right for them.

Use tools to measure peoples levels of knowledge,skills and confidence in managing their health and tailor support to themaccordingly.

Support people to develop and implementpersonalised care and support plans.

Review and update personalised care and supportplans at regular intervals.

Ensure personalised care and support plans arecommunicated to the GP and any other professionals involved in the personscare and uploaded to the relevant online care records, with activity recordedusing the relevant SNOMED codes.

Co-ordinate and integrate careMake and manage appointments for patients, relatedto primary, secondary, community, local authority, statutory, and voluntaryorganisations.

Help people transition seamlessly between secondaryand community care services, conducting follow-up appointments, and supportingpeople to navigate through the wider health and care system.

Refer onwards to social prescribing link workersand health and wellbeing coaches where required and to clinical colleagueswhere there is an unaddressed clinical need.

Regularly liaise with the range ofmultidisciplinary professionals and colleagues involved in the persons care,facilitating a co-ordinated approach and ensuring everyone is kept up to dateso that any issues or concerns can be appropriately addressed and supported.

Actively participate in multidisciplinary teammeetings in the PCN.

fIdentify when action or additional support isneeded, alerting a named clinical contact in addition to relevantprofessionals, and highlighting any safety concerns.

Record what interventions are used to supportpeople, and how people are developing on their health and care journey.

Keep accurate andup-to-date records of contacts, appropriately using GP and other recordssystems relevant to the role, adhering to information governance and dataprotection legislation.

Work sensitivelywith people, their families and carers to capture key information, whiletracking of the impact of care co-ordination on their health and wellbeing.

Record and collateinformation according to agreed protocols and contribute to evaluation reportsrequired for the monitoring and quality improvement of the service.

Undertake continual personal and professionaldevelopment, taking an active part in reviewing and developing the role andresponsibilities, and provide evidence of learning activity as required.

Adhere to organisational policies and procedures,including confidentiality, safeguarding, lone working, information governance,equality, diversity and inclusion training and health and safety.

Access relevant GPs to discuss patient relatedconcerns, and be supported to follow appropriate safeguarding procedures

Establish strong working relationships with GPs andpractice teams and work collaboratively with other care co-ordinators, socialprescribing link workers and health and wellbeing coaches, supporting eachother, respecting each others views and meeting regularly as a team.

Act as a champion for personalised care and shareddecision making within the PCN.

cDemonstrate a flexible attitude and be prepared tocarry out other duties as may be reasonably required from time to time withinthe general character of the post or the level of responsibility of the role,ensuring that work is delivered in a timely and effective manner.

Identify opportunities and gaps in the service andprovide feedback to continually improve the service and contribute to businessplanning.

Contribute to the development of policies and plansrelating to equality, diversity and reduction of health inequalities.

Work in accordance with the practices and PCNspolicies and procedures.

Contribute to the wider aims and objectives of thePCN to improve and support primary care.

Person Specification

Experience

• Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement
• Experience of data collection and using tools to measure the impact of services
• understanding of how to use System 1
• experience of working in primary care
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience of working within multi - professional team environments
• Experience of supporting people, their families and carers in a related role
• Experience or training in personalised care and support planning

Other

• Access to own transport
• Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social

Qualifications

• GCSE A-C IN English and Maths
• Meets a Disclosure and Barring Service (DBS) reference standards and criminal record checks

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.