PCN Care Coordinator

NHS; Greater London; On-site; GBP 25,000 - 30,000; Full time

Job summary

A health service organization in Greater London is seeking a proactive Care Coordinator to assist individuals, particularly the elderly and those with long-term conditions, in navigating and managing their healthcare. The role involves developing personalized care plans, collaborating with multidisciplinary teams, and ensuring high-quality support is provided to patients and their families. Ideal candidates will possess strong communication skills and a commitment to improving healthcare outcomes.

Qualifications

• Experience working in a multiprofessional team environment.
• Experience in data collection and measuring service impact.
• Experience or training in personalised care and support planning.

Responsibilities

• Work with people to develop and review personalised care plans.
• Coordinate care with GPs and primary care professionals.
• Support individuals in understanding their conditions and care options.

Skills

Excellent communication skills (written and oral)

Good interpersonal skills

Effective time management

Education

NVQ Level 3 in adult care or equivalent

Tools

MS Office

Job description

Care coordinators play an important role within a PCN to proactivelyidentify and work with people, including the frail/elderly and those withlong-term conditions, to provide coordination and navigation of care andsupport across health and care services.

They work closely with GPs and practice teams to manage a caseload ofpatients, acting as a central point of contact to ensure appropriate support ismade available to them and their carers; supporting them to understand andmanage their condition and ensuring their changing needs are addressed.

Main duties of the job

Work with people, their families and carers to improve theirunderstanding of the patients condition and support them to develop and reviewpersonalised care and support plans to manage their needs and achieve betterhealthcare outcomes.

Working with the practice to coordinate patients to the PCN home visting team.

Help people to manage their needs through answering queries,making and managing appointments, and ensuring that people have good qualitywritten or verbal information to help them make choices about their care.

Work collaboratively with GPs and other primary care professionalswithin the PCN to proactively identify and manage a caseload, which may includepatients with long-term health conditions, and where appropriate, refer back toother health professionals within the PCN.

Support the coordination and delivery of multidisciplinary teamswith the PCN.

Raise awareness of how to identify patients who may benefit fromshared decision making and support PCN staff and patients to be more preparedto have shared decision-making conversations.

Work with people, their families, carers and healthcare teammembers to encourage effective help-seeking behaviours.

Support PCNs in developing communication channels between GPs,people and their families and carers and other agencies.

About us

Greenwich PCN Alliance Limited has been running since 2020 and consists of 4 PCNs: Blackheath and Charlton PCN, Eltham PCN, Heritage PCN and Unity PCN. Our aim at Greenwich PCN Alliance Limited is support the improvement of primary care across Greenwich by providing support to Primary Care Networks (PCN) across Greenwich and recruiting Additional Roles via the the Additional Roles Reimbursement Scheme (ARRS)

Job responsibilities

Care coordinators play an important role within a PCN to proactivelyidentify and work with people, including the frail/elderly and those withlong-term conditions, to provide coordination and navigation of care andsupport across health and care services.

They work closely with GPs and practice teams to manage a caseload ofpatients, acting as a central point of contact to ensure appropriate support ismade available to them and their carers; supporting them to understand andmanage their condition and ensuring their changing needs are addressed.

This is achieved by bringing together all the information about apersons identified care and support needs and exploring options to meet thesewithin a single personalised care and support plan, based on what matters tothe person.

Care coordinators review patients needs and help them access theservices and support they require to understand and manage their own health andwellbeing, referring to social prescribing link workers, health and wellbeingcoaches, and other professionals where appropriate.

Care coordinators could potentially provide time, capacity andexpertise to support people in preparing for or following-up clinicalconversations they have with primary care professionals to enable them to be activelyinvolved in managing their care and supported to make choices that are rightfor them. Their aim is to help people improve their quality of life.

They will be caring, dedicated, reliable and person-focussed and enjoyworking with a wide range of people. They will have good written and verbalcommunication skills and strong organisational and time management skills. Theywill be highly motivated and proactive with a flexible. attitude, keen to workand learn as part of a team and committed to providing people, their familiesand carers with high quality support.

This role is intended to become an integral partof the PCNs multidisciplinary team, working alongside social prescribing linkworkers and health and wellbeing coaches to provide an all-encompassingapproach to personalised care and promoting andembedding the personalised care approach acrossthe PCN. Please note that the role of a care coordinator is not a clinicalrole.

Primary Responsibilities

Work with people, their families and carers to improve theirunderstanding of the patients condition and support them to develop and reviewpersonalised care and support plans to manage their needs and achieve betterhealthcare outcomes.

Working with the practice to coordinatepatients to the PCN home visiting team.

Help people to manage their needs through answering queries,making and managing appointments, and ensuring that people have good qualitywritten or verbal information to help them make choices about their care.

Work collaboratively with GPs and other primary care professionalswithin the PCN to proactively identify and manage a caseload, which may includepatients with long-term health conditions, and where appropriate, refer back toother health professionals within the PCN.

Support the coordination and delivery of multidisciplinary teamswith the PCN.

Raise awareness of how to identify patients who may benefit fromshared decision making and support PCN staff and patients to be more preparedto have shared decision-making conversations.

Work with people, their families, carers and healthcare teammembers to encourage effective help-seeking behaviours.

Support PCNs in developing communication channels between GPs,people and their families and carers and other agencies.

Conduct follow-ups on communications from out of hospital andin-patient services.

Maintain records of referrals and interventions to enablemonitoring and evaluation of the service.

Support practices to keep care records up-to-date by identifyingand updating missing or out-of-date information about the persons circumstances.

Contribute to risk and impact assessments, monitoring andevaluations of the service

Work withcommissioners, integrated locality teams and other agencies to support andfurther develop the role.

Key Tasks

1. Enableaccess to personalised care and support

-Take referrals for individuals or proactively identify people who could benefit from support through care coordination

-Have a positive,empathetic and responsive conversation with the person and their family andcarer(s) about their needs;

-Work towards increasingpatients understanding of how to manage and develop health and wellbeingthrough offering advice and guidance

-Develop anin-depth knowledge of the local health and care infrastructure and know how andwhen to enable people to access support and services that are right for them

-Use tools to measure peoples levels of knowledge, skills and confidence in managing theirhealth and to tailor support to them accordingly.

-Support people to develop and implement personalised care and support plans.

-Review and updatepersonalised care and support plans at regular intervals.

-Ensurepersonalised care and support plans are communicated to the GP and any otherprofessionals involved in the persons care and uploaded to the relevant onlinecare records, with activity recorded using the relevant SNOMED code

1. Coordinateand integrate care

-Making andmanaging appointments for patients, related to primary, secondary, community,local authority, statutory, and voluntary organisations

-Help peopletransition seamlessly between secondary and community care services, conductingfollow-up appointments, and supporting people to navigate through wider thehealth and care system

-Refer onwards tosocial prescribing link workers and health and wellbeing coaches where required

-Regularly liaisewith the range of multidisciplinary professionals and colleagues involved inthe persons care, facilitating a coordinated approach and ensuring everyone iskept up to date so that any issues or concerns can be appropriately addressed andsupported

-Activelyparticipate in multidisciplinary team meetings in the PCN as and whenappropriate

-Identify whenaction or additional support is needed, alerting a named clinical contact inaddition to relevant professionals, and highlighting any safety concerns.

-Record whatinterventions are used to support people, and how people are developing on theirhealth 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 coordination on their health and wellbeing;

-Encourage people,their families and carers to provide feedback and to share their stories aboutthe impact of care coordination on their lives

-Record andcollate information according to agreed protocols and contribute to evaluationreports required for the monitoring and quality improvement of the service

-Work with a namedclinical point of contact for advice and support.

-Undertakecontinual personal and professional development, taking an active part inreviewing and developing the role and responsibilities, and provide evidence oflearning activity as required

-Establish strongworking relationships with GPs and practice teams and work collaboratively withother care coordinators, social prescribing link workers and health andwellbeing coaches, supporting each other, respecting each others views and meetingregularly as a team

-Act as a championfor personalised care and shared decision making within the PCN

-Demonstrate aflexible attitude and be prepared to carry out other duties as may bereasonably required from time to time within the general character of the postor the level of responsibility of the role, ensuring that work is delivered ina timely and effective manner

-Identifyopportunities and gaps in the service and provide feedback to continuallyimprove the service and contribute to business planning;

-Contribute to thedevelopment of policies and plans relating to equality, diversity and reductionof health inequalities

-Work inaccordance with the practices and PCNs policies and procedures;

Contribute to the wider aims and objectives ofthe PCN to improve and support primary care.

-Adhere to organisational policies andprocedures, including confidentiality, safeguarding, lone working, informationgovernance, equality, diversity and inclusion training and health and safety

Person Specification

Experience

• Experience of working within multiprofessional team environments
• Experience of data collection and using tools to measure the impact of services
• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement.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 supporting people, their families and carers in a related role
• Experience or training in personalised care and support planning
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Personal Qualities

• Polite and confident
• Flexible and cooperative
• Motivated, forward thinker
• Problem solver with the ability to process information accurately and effectively, interpreting data as required
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure/in stressful situations
• Effectively able to communicate and understand the needs of the patient
• Commitment to ongoing professional development
• Punctual and committed to supporting the team effort
• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
• Ability to identify risk and assess / manage risk when working with individuals
• Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• Ability to demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• High level of written and verbal communication skills
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Ability to provide motivational coaching to support peoples behaviour change

Skills

• Excellent communication skills (written and oral)
• Competent in the use of Office and Outlook
• Effective time management (planning and organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving and analytical skills
• Ability to follow clinical policy and procedure
• Understanding of clinical risk management
• Understanding of the audit process

Skills and Knowledge

• Knowledge of the personalised care approach
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Knowledge of how the NHS works, including primary care and PCNs
• Ability to recognise and work within limits of competence and seek advice when needed
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
• Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social

Qualifications

• Proficient in MS Office and web-based services
• NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
• Demonstrable commitment to professional and personal development is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute

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.