PCN Care Co-ordinator

North Sedgemoor PCN; Swindon, Highbridge; On-site; GBP 22,000 - 32,000; Full time

Job summary

North Sedgemoor PCN is seeking a Care Coordinator to work within its Primary Care Network and be part of the wider social prescribing team. You will help coordinate care, manage referrals, and support MDT meetings across several practices in the network.

The role focuses on promoting personalised care, improving continuity, and working closely with GPs, nurses, and other professionals. A flexible, multi-disciplinary environment with opportunities for training is offered.

Qualifications

• Minimum two years Primary Care experience in administration or reception roles.
• Experience with EMIS Web and other clinical systems such as AccuRX and C the Signs.
• IT literate, including ability to use Microsoft Office (Outlook, Word, Excel, Teams, PowerPoint).
• Understanding of handling confidential information and patient data.
• Able to work as part of a multi-disciplinary team.

Responsibilities

• Arrange the daily PCN-led MDT meetings and coordinate integrated care.
• Take notes of MDT meetings, disseminate actions, and chase progress.
• Manage reporting requirements within NHSEDES specifications.
• Receive and collate information from transfers of care and present to the MDT.
• Signpost service users to relevant services and support referrals as needed.
• Support with administration and patient management across the PCN.

Skills

IT literacy

Microsoft Office

Teamwork

Tools

EMIS Web

AccuRX

C the Signs

Job description

This is an exciting opportunity to join our dynamic team within North Sedgemoor PCN (practices include: Axbridge, Cheddar, Brent and Symphony North, consisting of Berrow, Burnham and Highbridge). The postholder will be part of the Primary Care Network (PCN) team and willalso be part of our wider social prescribing team.

Main duties of the job

Care Co-ordinators contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions. An ethos of promotion of independence and partnership-working is integral to this post. They play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

Care Co-ordinators work closely with the GPs and other primary care colleagues within the PCN and within the practices to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers (if appropriate), and ensuring that their changing needs are addressed. They focus on the delivery of personalised care to reflect local PCN priorities, health inequalities or at-risk groups of patients.

A key part of the role of a Care Coordinator role is with the One Team (MDT), improving the continuity of care by acting as a point of contact for, families and professionals, such as MDT members and in-reach specialists.

About us

North Sedgemoor PCN brings together GP practices caring for around 50,000 people across Burnham on Sea, Brent, Highbridge, Cheddar and Axbridge. We are clinically led, collaborative and community focused. Our team includes GPs, Occupational Therapists, Pharmacists, Care Coordinators, Health Coaches, Paramedics, Digital & Transformation Leads and Service Leads.

We are a learning organisation. You will have a named supervisor. We value curiosity, high standards and kindness. Ideas are welcomed and improvement is part of daily work.

This is an exciting time to join us. We are scaling services and modernising how we deliver urgent and planned care in practices, in peoples homes and in care homes. You will be supported by clear pathways, friendly colleagues and a welcome team who help new colleagues settle in.

You will receive an NHS pension if eligible, generous annual leave and access to well-being resources.

Job responsibilities

• Overall responsibility for arranging the daily PCNled MDT meetings and the smooth running of integrated care within the teamsetting. A key role of the Care Coordinator is to ensure that all new referralsare identified, and information circulated to team members in advance of themeeting.
• Take notes of MDT meetings and disseminate; chaseprogress against actions identified in these meetings and ensure follow upwhere necessary.
• Manage reporting required and associated within the NHSEDES specifications for required services.

PatientIdentification.Utilisepopulation health intelligence to proactively identify and work with a cohortof patients to deliver personalised care

• Receive and collate information from transfers ofcare (including hospital admissions and discharges) plus out of hours calls andpresent this information to the MDT as required.
• Liaise with service providers and clinicians to identifyfrequent flyers, and new service users utilising risk stratification toolsprovided and present this information to the daily MDT meetings.
• Support the completion of new referrals by checkingcriteria, and where criteria have been met, direct referral to the MDT.
• Signpost team members, service users and carers torelevant services.
• 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 ofpatients identified through the MDT or practice.
• Support patients to utilisedecision aids in preparation for a shared decision-making conversation.
• Holistically bring togetherall of a persons identified care and support needs and explore options to meetthese within a single personalised care and support plan (PCSP), in line withPCSP best practice, based on what matters to the person.
• Help people to manage theirneeds through answering queries, making and managing appointments, and ensuringthat people have good quality written or verbal information to help them makechoices about their care.
• Support people to take uptraining and employment, and to access appropriate benefits where eligible.
• Support people to understandtheir level of knowledge, skills and confidence (their Activation level) whenengaging with their health and well-being, including through the use of thePatient Activation Measure.
• Assist people to accessself-management education courses, peer support or interventions that supportthem in their health and well-being and increase their activation level.
• Explore and assist people toaccess personal health budgets where appropriate.
• Refer or liaise with theHealth Coaches and Village Agents as appropriate.

Communicationand collaborative working relationships

• Demonstrate ability to workas a member of a team.
• Can recognise personallimitations and refer to more appropriate colleague(s) when necessary.
• Actively work towarddeveloping and maintaining effective working relationships both within andoutside the PCN or group of PCNs.
• Liaises with otherstakeholders as needed for the collective benefit of patients including but notlimited to Patients GP, Nurses, other practice staff and other healthcareprofessionals including pharmacists and pharmacy technicians from provider andcommissioning 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 allpartners, 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 andin-reach specialists.
• Meet regularly with the clinical lead and reviewcase load and MDT function.
• Keep the MDT and OHP organisation abreast of goodnews stories.
• Provide background information about individuals forthe daily MDT meetings.
• Communicate effectively with service users and theirfamilies/carers, and provide coordination across health and care services workingclosely with social prescribing link workers, health and well-being coaches, andother primary care professionals.
• Manage and prioritise workload on a daily basis anddeal with the competing demands of the MDT.

Otherresponsibilities

• To act at all times in an anti-discriminatory manner.
• To be able to plan and respond to workload accordingto operational priorities.
• To support the delivery of these functions acrosswider locality areas where necessary.
• To undertake any training required to maintaincompetency including mandatory training.
• To contribute to, and work within a safe workingenvironment.
• The Care Coordinator must at all times carry outduties and responsibilities with due regard to the GP Practices equalopportunity policies and procedures.
• The Care Coordinator is expected to takeresponsibility for self-development on a continuous basis, undertakingon-the-job training as required.
• The Care Coordinator must be aware of individualresponsibilities under the Health and Safety at Work Act, and identify andreport as necessary any untoward accident, incident or potentially hazardousenvironment.
• Communicate effectively and sensitively and uselanguage appropriate to a patient and carer/relatives condition and level of understanding.
• Effectively use all methods of communication and beaware of and manage barriers to communication.
• Effectively recognise and manage challenging behaviours,carers and or relatives
• Provide information to patients, their carersand/or relatives on behalf of the team.
• The PCN will ensure the PCNs Care Coordinator can discuss patientrelated concerns and be supported to follow appropriate safeguarding procedures(e.g., abuse, domestic violence and support with mental health) with a relevantGP.

SupportingCare Delivery

• Be the point of liaison for service users andinterface with all health and social care professionals, including keepingeveryone informed and updated.
• Follow through actions identified by the MDTincluding arranging tests, referrals, signposting, etc.
• Follow through with service users and othersinvolved to ensure all services and care arrangements are in place.

Autonomy/Scopewithin Role

• The post holder will be required to work withinclearly defined organisational protocols, policies and procedures.

Key Relationships

Key Working Relationships Internal

• Clinical Leadfor the MDT.
• GPs and Generalpractice teams within the PCN.
• PCN Manager.
• MDT membersincluding but not exhaustive: Clinical Pharmacists, technicians, DistrictNurses, LARCH Team, OPMH, IRT, Adult Social Care, Paramedics, SocialPrescribing Link Workers, Village Agents.

Key Working Relationships External

• GPs fromneighbouring PCNs.
• Serviceproviders.
• Voluntaryservices.
• Carers/relatives.

Health and Safety/Risk Management

• The post-holder must comply atall times with the organisation and Practices Health and Safety policies, inparticular by following agreed safe working procedures and reporting incidentsusing the organisations Incident Reporting System.
• The post-holder will complywith the Data Protection Act (1984), The General Data Protection Regulations(2018) and the Access to Health Records Act (1990).
• The post-holder will complywith all necessary training requirements relevant to the role as identified bythe organisation; in particular the post holder must complete the specifiedcare coordinator training delivered by the Personalised Care Institute.

Equality and Diversity

• The post-holder mustco-operate with all policies and procedures designed to ensure equality ofemployment. Co-workers, patients and visitors must be treated equallyirrespective of gender, ethnic origin, age, disability, sexual orientation,religion etc.

Respect for PatientConfidentiality

• The post-holder should alwaysrespect patient confidentiality and not divulge patient information unlesssanctioned by the requirements of the role.

Special Working Conditions

• The post-holder is required totravel independently between practice sites (where applicable), and to attendmeetings etc. hosted by other agencies.

Qualifications

• Ongoing internal and external training to keep up to date with changes/ developments.

Experience

• A minimum of two years Primary Care experience working with health professionals within administration or reception roles.
• Experience of EMIS Web and other clinical systems such as AccuRX and C the Signs.
• IT literate, including ability to use all Microsoft platforms (Outlook, Word, Excel, Teams, Powerpoint etc).
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
• Able to work as part of a team.
• Excellent organisational and administration skills
• Working in a multi-disciplinary setting where influence and negotiation is required.
• Knowledge/familiarity with medical terminology.
• Working in a busy and demanding environment whilst delivering in a timely manner.
• Understanding of current issues facing the NHS.
• Understanding and experience of TeamNet.
• Able to use NHS Choices website effectively.
• Understanding of health and social care processes.

Values, Drivers and Motivators

• Willingness to undergo further training or development.
• Requires a flexible approach, and a highly motivated post holder. The role may need to be reviewed and developed in the future in line with changing priorities.
• Access to and ability to use transport as travel between sites across the county will be required for meetings and training.
• Willingness to undergo further training and development as the job develops.

Aptitude and Personal Qualities

• Professional attitude and assertive approach.
• Committed to development.
• Conscientious, hardworking and self- motivated to work with minimal supervision.
• Creative and tenacious in finding solutions to difficult problems.
• Ability to work with information, clinicians, social workers and managers.
• Ability to meet deadlines and work under pressure.
• Ability to engage and sustain relationships with all professionals, other organisations and service-users.
• Approachable and flexible.
• Honest and reliable.
• Sensitive to patients needs.
• Adaptable to change.

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.