PCN Care Coordinator in London

We are looking for 1 WTE PCN Care Coordinators with excellent communication and administrative skills to work with the GPs and other clinicians within the Waterloo Health Centre. You will be working with GPs and other clinicians to assist patients in the management of their care. One of the successful care coordinators will concentrate on providing administration support across practices as well as care coordination. You will be non-judgmental, empathetic as the first point of contact for patients, clinicians and community carers, identifying personalised care plans, engaging them in training and employment to improve their wellbeing. Having excellent time management skills will be important to manage your workloads and deliver role objectives within the timescales.

Main duties of the job:

• As a Care Coordinator, you will play a crucial role in supporting patients in preparing for or in following-up clinical conversations they have with primary care professionals.
• You will work closely with the GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, ensuring that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
• You will focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification.

About us:

North Lambeth Primary Care Network consists of 6 practices (Hurley and Riverside Practices, Lambeth Walk Group Practice, Mawbey Group Practice, South Lambeth Road Group Practice, Waterloo Health Centre and the Vauxhall Surgery) working together to provide excellent patient care to a population of over 69,000 patients. As a Network, we are striving to be at the forefront of PCN development and are involved in several exciting pilot projects.

Job responsibilities:

• Undertake work in line with PCN directed priorities.
• Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids.
• Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance.
• Raise awareness of health promotion and NHS health checks in practices.
• Work with Member Practices to facilitate the evaluation of treatment programmes that promote health and well-being.
• Co-ordinate clinics, liaising with the schedulers and contacting the identified patients with appointments.
• Manage patient initiated calls for help/signposting etc., booking into named GP urgent care slots/tel slots if necessary.
• Document and monitor aspects of patient co-ordination and service delivery, supporting data collection and audit using the patient administration system.
• Demonstrate the ability to recognise and respond appropriately when faced with a sudden deterioration or emergency situation, alerting the team or enabling a rapid response.
• Organise and prioritise own workload; the postholder should be comfortable working independently and as a committed member of the multi-disciplinary team.
• Support national screening programmes.
• Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact.
• Direct liaison with multi-agencies to coordinate care for patients.
• Refer to PCN social prescribing link workers where a patient is identified as potentially benefiting from this service.
• Support patient/carer contact roles, and collate patient and carer feedback on the experience.
• Support Quality and Outcome Frameworks and other DES/LES specifications.
• Maintain and develop engagement with all practice staff and encourage best practice.
• Act as the first port of call for patients in their caseload in relation to their care.
• Bring together all of a person's identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP), in line with PCSP best practice.
• Help people to manage their needs, answering their queries and supporting them to make appointments.
• Support people to take up training, employment and access appropriate benefits where eligible.
• Raise awareness of shared decision-making and decision-support tools, and assist people to be more prepared to have a shared decision-making conversation.
• Ensure that people have good quality information to help them make choices about their care.
• Support people to understand their level of knowledge, skills and confidence their Activation level when engaging with their health and wellbeing, including using the Patient Activation Measure.
• Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
• Explore and assist people to access personal health budgets where appropriate.
• Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles.
• Support the coordination and delivery of MDTs within PCNs, managing MDT meetings for these patients and identifying issues to be addressed, liaising with other agencies if necessary as well as GPs, Pharmacists and Nursing team.
• Liaise directly with Care Homes and other key providers, to identify patients for discussion at MDT, and compile and circulate relevant information to attendees.

Confidentiality:

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients, their carers, practice or staff information. All such information from any source is to be regarded as strictly confidential. Information relating to patients, carers, colleagues, or the members practices may only be divulged to authorised persons in accordance with PGPA policies and procedures relating to confidentiality and the protection of personal and sensitive data, or under the guidance of your manager.

This role profile is not exhaustive, and you may be directed to complete other tasks according to the skills and requirements for individual roles. These duties will always be reasonable and deemed within the expectations of your position.

Person Specification:

Personal Qualities & Attributes:

• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
• Able to work as part of a team.
• Able 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, partner agencies and stakeholders.
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues in PCN and the various Practice teams.
• Demonstrates personal accountability, emotional resilience and works well under pressure.

Skills and knowledge:

• Knowledge of the personalised care approach.
• Advanced experience of using Word, Excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports.
• Creative problem solver and willing to search for hard-to-find information.
• Knowledge of general practice clinical systems, such as EMIS ERS, Footfall.
• Ability to read large amounts of information and extract the salient points, to analyse data and report on findings.

Other:

• Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions.
• Access to own transport and ability to travel across the locality on a regular basis.
• Continued commitment to improve skills and ability in new areas of work.

Experience:

• Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work).
• Experience of data collection and providing monitoring information to assess the impact of services.
• Experience of partnership/collaborative working and of building relationships across a variety of organisations.
• Experience of working with or in general practice.
• Working in a multi-disciplinary setting where influence and negotiation is required.
• Knowledge/familiarity with medical terminology.
• Experience of supporting people, their families and carers in a related role (including unpaid work).
• Experience in use of databases.
• Vulnerable adults awareness.
• Experience of care of the elderly.

Qualifications:

• ECDL or equivalent.
• Demonstrable commitment to professional and personal development.
• Training in motivational coaching and interviewing or equivalent.

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.