PCN Care Coordinator

The NHS is seeking a Network Care Coordinator in Ross-on-Wye to facilitate health and wellbeing for diverse patient populations. This role requires effective communication, collaboration with healthcare professionals, and a commitment to reducing health inequalities. Responsibilities include managing patient care plans and supporting individuals in accessing necessary health services.

Home or remote working option

Qualifications

• Experience of working in a health or social care setting.
• Knowledge of personalised care concepts.
• Ability to build relationships across organizations.

Responsibilities

• Coordinate care for identified patients and manage their care plans.
• Support patients with accessing personalized health services.
• Build relationships with healthcare teams and community services.

Skills

Empathy

Interpersonal communication

Education

GCSE English or equivalent

GCSE Mathematics or equivalent

ECDL or equivalent IT skills

Tools

EMIS

TheNetwork Care Coordinator (NCC) role acts as the central care coordination rolewithin the S&W PCN. Supporting the networks Health & Wellbeing Teamand the practices in executing on their contractual requirements, the role willact as the central point of contact for outreach to a range of patientsidentified as requiring clinical or wellbeing intervention. These will include frail patients, patients atrisk of Health Inequalities and patients with predeterminants of cardiovasculardisease.

Main duties of the job

TheNCCs role requires them to be able to work with, and understand the roles of,a variety of different people working in the practice and across the PCN includingdoctors, nurses, healthcare assistants, social prescribing link workers,physiotherapists, health and wellbeing coaches and pharmacists.

They will identify and work with individuals in need of proactivesupport with the aim of providing advocacy, encouraging independence, a healthylifestyle, mental wellbeing, and social connectivity. They may be given a caseload ofidentified patients and be required to ensure that their changing needs areaddressed by taking into account local priorities, health inequalities and/orpopulation health management risk stratification.

About us

South& West Herefordshire PCN is made up of six practices centred around themarket town of Ross-on-Wye: Alton StreetSurgery, Pendeen Surgery, Fownhope Surgery, Much Birch Surgery, Golden ValleyPractice and The Surgery Kingstone. Thenetwork covers a wide geographic area offering traditional General Practicesupport to our patients centred around the communities they live in. The position will be hosted by Alton StreetSurgery as the employer.

Alton Street Surgery is well established and has a very good reputation for patient care and accessibility. In 2018 the surgery received a rating of Outstanding from the CQC. The practice provides care to approximately 11,600 patients in Ross-on-Wye and surrounding rural areas.

Job responsibilities

The following are the core responsibilities of the NCC. There may be, on occasion, a requirement to carry out other tasks, as directed by your line manager. This will be dependent upon factors such as workload and staffing levels.

Enable access to personalised care and support

• To work closely with practice, PCN teams and other healthcare roles, the NCC is to identify and work with a cohort of people to support their personalised care requirements, using any available decision support tools. These tools may involve new technology and medical devices that the PCN chooses to adopt.
• To collate all of a patients identified care and support needs and review the options to meet these needs in line with best practice and based on what matters to the person.
• To help people to manage their needs by answering their queries and supporting them in making appointments.
• To provide patients with high quality, easy to understand written and verbal information to assist them in making choices about their care and allow them to understand and build confidence in their own health and care management.
• Have basic safeguarding processes in place for vulnerable individuals.

Co-ordinate and integrate care:

• Be the initial point of contact for patients identified by the PCNs outreach teams to coordinate onward referrals to care and support. These may include referrals to other staff within the PCN as well as to partners in our Integrated Neighbourhood Team, such as Wye Valley Trust partners and the voluntary sector.
• To assist patients to access self-management education courses, peer support or interventions that support them in their health and well-being
• Work closely with and develop strong relationships with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated delivery of the patients care plan, without requiring a further referral from the GP.
• To support in the delivery of the PCN enhanced service contract and other local and national contracts held by the network.
• Organise, support and attend relevant meetings when required including multi-disciplinary team meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance.
• Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.
• Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
• Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care co-ordination on their health and wellbeing.
• Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.

Person Specification

Skills

• Active and empathetic listening, provide personalised support in a non-judgemental way
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Good interpersonal communication skills, both written and verbal with patients, colleagues, family members and partner agencies
• Effective questioning, ability to build trust and rapport with patients and colleagues
• Ability to manage and prioritise own work to meet deadlines.
• Ability to work effectively as part of a team.
• Good level of accuracy and attention to detail.
• Understanding of personalised care and the comprehensive model of personalised care
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Use of health literate communication techniques
• Ability to provide motivational coaching to support peoples behaviour change

Experience

• Experience of using IT systems such as EMIS
• Experience of working in a health or social care setting
• Experience of partnership/collaborative working and of building relationships across a variety of organisations
• Experience of providing one to one and/or group support
• Experience of minute-taking within an MDT environment
• Completed a two day PCI accredited care co-ordination training course or be willing to complete one prior to taking referrals
• Knowledge of the core concepts and principles of personalised care, shared decision making, patient activation, health behaviour change, self-efficacy, motivation and assets-based approaches.

Personal Qualities or Attributes

• Reliable, conscientious and flexible approach to work.
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• To be able to work independently on own initiative but aware of own limitations within the scope of the role
• Ability to maintain confidentiality

Qualifications

• GCSE English or equivalent level
• GCSE Mathematics or equivalent level
• ECDL or equivalent level of keyboard / IT skills

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.

Part-time,Flexible working,Home or remote working

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