PCN Care Co-ordinator (Cardiovascular Disease)

NHS Jobs; Tadley; On-site; GBP 30,000 - 40,000; Full time

Job summary

A healthcare provider in Tadley is seeking a PCN Care Co-ordinator specialized in Cardiovascular Disease. The role involves working closely with multidisciplinary teams to improve patient outcomes through personalized care plans. Ideal candidates should possess strong collaboration, patient management, and IT skills, and have a keen interest in using technology for healthcare improvement. This position supports the development of comprehensive care for individuals with long-term health conditions.

Qualifications

• Experience working with long-term health conditions, particularly Cardiovascular Disease.
• Strong understanding of personalized care and support planning.
• Ability to work in a multidisciplinary team environment.

Responsibilities

• Identify and manage a caseload of patients with CVD.
• Coordinate and navigate health services for patients.
• Maintain records of referrals and interventions.

Skills

Collaboration with healthcare professionals

Patient management

Communication skills

Data analysis (EMIS)

IT proficiency

Job description

PCN Care Co-ordinator (Cardiovascular Disease)

The Care Co-ordinator will work as an integral part of the PCN's multidisciplinary team (MDTs), collaborating with the existing CVD Care Co-ordinator, Social Prescribers, and Health and Wellbeing Coaches to provide comprehensive, personalized care and promote the personalized care approach across the PCN. They will be based within two Practices within the PCN.

The post holder will:

1. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload of patients with long-term health conditions, specifically those with Cardiovascular Disease (CVD), and refer back to other health professionals within the PCN as appropriate. This will involve regularly running reports from clinical systems such as EMIS.
2. Provide proactive support to the Practices' CVD teams and the PCN to ensure achievement of the CVD-specific QOF targets.
3. Participate in daily and weekly Multi-Disciplinary Team (MDT) One Team meetings with the PCN team and community services if required.
4. Coordinate and navigate services for patients and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals to ensure patients receive a joined-up service and appropriate support.
5. Work with patients, their families, and carers to improve understanding of the patient's condition and support them in developing and reviewing personalized care and support plans to manage their needs and improve healthcare outcomes.
6. Ensure patients can access community services, both free and chargeable, based on detailed knowledge of access arrangements, eligibility, and service content. Connect existing local statutory and voluntary services to provide wrap-around support.
7. Assist patients in managing their needs by answering queries, scheduling appointments, and providing high-quality information to support informed care decisions. Refer patients to social prescribing link workers and health and wellbeing coaches as needed.
8. Help patients access assessments for Adult Social Care when appropriate and provide information related to personal budgets.
9. Follow up on communications from out-of-hospital and inpatient services.
10. Maintain records of referrals and interventions for monitoring and evaluation.
11. Support the development of communication channels between GPs, patients, families, carers, and other agencies.
12. Assist practices in keeping care records current by identifying and updating missing or outdated information about patients' circumstances.
13. Contribute to risk and impact assessments, and monitor and evaluate the service.
14. Review and update personalized care and support plans periodically, ensuring they are communicated to relevant professionals and uploaded to online care records using SNOMED codes.
15. Raise awareness of shared decision-making and support staff and patients in preparing for these conversations.
16. Take referrals or proactively identify individuals who could benefit from care coordination support.

Please note that the role involves using various IT tools, including AI development, requiring openness, enthusiasm, and interest in technology.