Care Co-ordinator in Cannock

Cannock Villages Primary Care Network is looking to employ a keen and highly motivated Care Coordinator to join our growing multi-disciplinary team. It will be an opportunity to work with Allied Health Professionals to enhance the service we offer to our patients.

Main duties of the job:

• Proactively identify and work with a cohort of patients to support their personalised care requirements.
• Provide coordination and navigation support using digital tools to help patients and their carers access appropriate health and care services.
• Develop and maintain personalised care and support plans based on individuals' needs and what matters to them.
• Support patients in managing their conditions, answering queries, and navigating appointments.
• Ensure that patients have access to high-quality information to support informed choices about their care.
• Promote preventative healthcare and continuity of care.

About us:

The Cannock Villages Primary Care Network consists of 11 Practices with a combined list size of approx. 61k. The PCN has great access links and is located near junction 11 of the M6 motorway.

Job responsibilities:

• Work with the PCN Practices to coordinate and deliver the health inequalities and Cancer areas of the network DES.
• Take referrals for individuals or proactively identify people who could benefit from support through care coordination.
• Act as a point of contact between GP patients and carers and other agencies.
• Liaise with GPs and practice teams to identify patients who are elderly, frail or who have long term health needs and support.
• Work with the multi-disciplinary team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.
• Provide these cohorts of people signposting to identified services in order to maintain their independence and improve their health and well-being.
• Assist with personal care plans for individual patients, ensuring preventative actions are detailed to support the appropriate use of services.
• Communicate the care plan to the GP and any other professionals involved in the person's care and upload to the relevant records.
• Ensure that identified patients receive the right level of help at the right time and help them to experience a joined-up service by liaising with relevant organisations.
• Liaise with other agencies, Primary, Secondary and specialist care services to ensure timely and appropriate engagement as required.
• Support patients to access community care assessments as well as carers assessments.
• Identify unpaid carers and direct them to access services as appropriate to provide them with support.
• Follow up on communications from out of hospital and in-patient services regarding changes in condition of patients to support the practice to respond proactively to potentially unmet needs.
• Undertake visits or telephone contact to manage patients on the PCN's case load following any unplanned hospital admissions where appropriate.
• Attend multi-disciplinary meetings plus any other meetings where there is a need to discuss patients on case load. Updates between meetings to be shared with the Practices.
• Run regular patient searches using Emis in order to have an up-to-date record of progress of achievement of Key Performance Indicators.
• Support the PCN in providing KPI reports for submission as requested.
• Collate data for submission to the ICB (Integrated Care Board) or NHSE.
• Arrange meetings and produce minutes of those meetings.
• Work with the PCN Operations Manager to produce policies and protocols.

Qualifications:

• You will have experience working within healthcare or the voluntary/community sector, supporting vulnerable groups.
• Excellent IT Skills including Microsoft Office and experience with GP Clinical System (Emis or equivalent).
• You will have strong listening and communication skills.
• Ability to work well in a team; however, also able to work independently without supervision.
• You will be able to review and improve working practices with shared experience across the PCN.
• Minimum of 2 years experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field.

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.