PCN Care Co-ordinator - Health Inequalities role

NHS; Bodmin; On-site; GBP 25,000 - 35,000; Full time

Job description

To work closely with our PCN Practices and the multidisciplinary team in coordinating all key activities including access to services, advice, and information, and ensuring health and care planning is timely, efficient, and patient-centred. The post holder will help to support patients to interact and engage with everyday life through activities designed to develop, maintain, or retrain skills for people with a cognitive, physical, or mental disorder, condition, or illness. You will support the provision of continuity of care and act as a point of contact for families, residents, and professionals for identified patients as part of the practice caseload.

The job description and person specification are an outline of the tasks, responsibilities and outcomes required of the role. The job holder will carry out any other duties as may be reasonably required by their line manager.

This role will work alongside our high intensity patients, and will tackle health inequalities, as part of work within areas of deprivation.

Main duties of the job

PRIMARY DUTIES AND AREAS OF RESPONSIBILITIES

1. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribers, and other primary care professionals.
2. Utilise population health intelligence to proactively identify and work with a cohort of patients to co-ordinate personalised care.
3. Support PCN and practice staff to be prepared to have shared-decision making conversations including utilising decision aids and tools, and support clinicians to understand the level of knowledge, skills and confidence for patients (their activation level) when engaging with their health and wellbeing.
4. Help to co-ordinate and manage care needs through answering queries, making and managing appointments and where appropriate have written or verbal information to help patients make choices about their care.
5. You will co-ordinate and actively participate in weekly MDT planning for a cohort of patients that may include mental health, frailty, and other clinical and social needs, liaising with services as required.

About us

Our Network consists of Lostwithiel Medical Practice, Fowey River Practice, Middleway Surgery, and Bosvena Health.

Our Practices will provide medical cover for rural and semi-rural areas across the middle of Cornwall with a combined population of 43,500 patients. Our demographic is mixed, and geographically we will cover the heart of the county incorporating moorland and coastal areas.

Job responsibilities

BOSVENA 3 Harbours Primary Care Network

JOB DESCRIPTION

LOCATION: General Practice within the Bosvena 3 Harbours PCN

This role exists under the Primary Care Network Additional Roles Reimbursement Scheme.

JOB PURPOSE:

To work closely with our PCN Practices and the multidisciplinary team in coordinating all key activities including access to services, advice, and information, and ensuring health and care planning is timely, efficient, and patient-centred. The post holder will help to support patients to interact and engage with everyday life through activities designed to develop, maintain, or retrain skills for people with a cognitive, physical, or mental disorder, condition, or illness. You will support the provision of continuity of care and act as a point of contact for families, residents, and professionals for identified patients as part of the practice caseload.

The job description and person specification are an outline of the tasks, responsibilities and outcomes required of the role. The job holder will carry out any other duties as may be reasonably required by their line manager.

PRIMARY DUTIES AND AREAS OF RESPONSIBILITIES

1. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribers, and other primary care professionals.
2. Utilise population health intelligence to proactively identify and work with a cohort of patients to co-ordinate personalised care.
3. Support PCN and practice staff to be prepared to have shared-decision making conversations including utilising decision aids and tools, and support clinicians to understand the level of knowledge, skills and confidence for patients (their activation level) when engaging with their health and wellbeing.
4. Help to co-ordinate and manage care needs through answering queries, making and managing appointments and where appropriate have written or verbal information to help patients make choices about their care.
5. Holistically bring together all of a person's identified care and support plan, in line with best practice, based on what matters to the person.
6. Where appropriate refer to people to take up training and employment, and to access appropriate benefits, education courses, peer support, and/or personal health budgets where applicable.
7. As part of the multidisciplinary team, build relationships with staff in the GP practices, attending relevant meetings, providing information and feedback on care coordination priorities.
8. Be proactive in developing strong links with local agencies, and in encouraging equality and inclusion.
9. Liaise directly with care homes and other key providers, and compile and circulate relevant information across stakeholder groups.
10. Understand and adhere to safeguarding protocols for vulnerable individuals.
11. Capture key information to enable comprehensive and accurate records of support, inputting these into clinical systems as required and adhering to data protection legislation.

CONFIDENTIALITY

The post holder may have access to confidential information relating to patients, their carers, practice staff and other healthcare workers. They may also have access to information relating to the Federation 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 Federation may only be divulged to authorised persons in accordance with the Federation's policies and procedures relating to confidentiality and the protection of personal and sensitive data.

HEALTH & SAFETY

The post holder will assist in promoting and maintaining their own and others' health, safety and security as defined in the Federation's Health & Safety Policy.

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 the practice procedures and policies and current legislation.
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.

Person Specification

Qualifications

• Educated to GCSE level or equivalent.
• Desirable if hold a relevant NVQ Level 3 qualification or equivalent.

Experience

• Experience of working with healthcare professionals and/or previous experience in the NHS or social care.
• Experience coordinating with multiple stakeholders or individuals to meet specified outcomes.
• Experience providing advice/signposting.
• Experience using a patient clinical system.
• Awareness of how and when to signpost.
• Knowledge of safeguarding interventions and an awareness of the Mental Capacity Act.
• Skilled in the use of person-centred measurement and outcomes delivery.
• Knowledge of a range of local community groups which support wellbeing (desirable).
• Awareness of relevant Health and Social Care legislation and a developed knowledge of crisis intervention (desirable).
• Experience of undertaking quality improvement activity (desirable).
• Sound understanding of disease prevention and the NHS choices website (desirable).

PRACTICAL, INTELLECTUAL, ANALYTICAL AND ORGANISATIONAL SKILLS

• Excellent verbal communication skills with the ability to communicate effectively at all levels including with patients, carers, specialist services, GPs and colleagues.
• Good technical literacy with e.g. Word, Excel, and experience using a clinical system such as EMIS Web.
• Able to work independently and manage own workload.
• Able to build strong professional relationships.
• Demonstrate experience of effective planning and organisation skills to deliver targets to deadlines.
• Proven record of excellent written communication skills and a high level of health literacy.
• Understanding of social determinants of health and how these can be addressed with patients.
• Able to analyse and interpret information and present results in a clear and concise manner.

DEPOSITION / PERSONAL

• Creative, flexible and sensitive approach to working with people with diverse support needs.
• Ability to motivate people.
• Ability to reflect on and share best practice with peers.
• Able to travel locally as required.
• Passionate about combatting disadvantage and inequality in healthcare.
• Able to work as part of a team.

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.