PCN Care Coordinator

Pendle West PCN is looking for a Care Co-ordinator to join our growing team. This is an exciting opportunity to help deliver integrated care based around the needs of our patient population. Working very closely with the practice and multidisciplinary team (MDT) within the PCN, these roles are pivotal in ensuring all patients receive the best possible care and service. The role will suit individuals with a strong administrative background. The postholder will work on specific projects allocated and also support the PCN management team. Hours are negotiable between 30-37.5 per week. Applicants need to be flexible to work across our geographical area of Nelson and Brierfield. General practice experience is desirable but not essential.

Main duties of the job

Our aim is to ensure our patients feel supported and have access to the services that are right for them, helping them to manage their own needs where possible, promote and encourage patient awareness, skills and confidence, and to help patients maintain and make decisions about their own health and wellbeing. There will be a focus on those patients who are harder to reach or may have access or unmet needs.

About us

Pendle West PCN is made up of seven GP practices within Nelson and Brierfield and covers a local population of circa 53,000. The PCN has a strong commitment to leading and developing change in the local healthcare community. We have a vision for healthcare that is sustainable, high quality and offers excellent patient and staff experience. Our services are designed to reflect the needs of the population they serve and promote lifestyle health and wellbeing. We offer development and training supported by a full complement of experienced clinical support staff, non-clinical support staff and management.

Job responsibilities

Responsible to: Clinical Director
Hours of work: 30+
Salary: Equivalent to Band 4 Agenda for Change

Job Summary

To provide co-ordination and navigation for people and their carers across health and care services, working closely with Social Prescribing Link Workers, Health and Wellbeing Coaches and a range of primary care professionals within Pendle West Primary Care Network (PCN). The Care Co-ordinator will be a member of the PCN Multidisciplinary Team (MDT) and will be responsible for co-ordinating and facilitating elements of care for people registered with our 7 local GP Practices to improve the quality of care and support they receive. The Care Co-ordinator will support the co-ordination and delivery of MDT meetings within the PCN. A key part of the role is also to provide organisational and administrative support to the PCN team. The duties of this post will be subject to review regularly.

Primary Duties and Areas of Responsibility

• To work closely and in partnership with the GP practices and health and wellbeing team within the PCN.
• To utilise local population health information to proactively identify and work with a cohort of patients to deliver personalised care.
• To holistically bring together all of a person's identified care and support needs, and explore the options to meet these, within a single personalised care and support plan (PCSP), in line with best practice and based on what matters to the person.
• To help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
• To support people to take up training and employment, and to access appropriate benefits where eligible.
• To support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their personal health and wellbeing, including through the use of the Patient Activation Measure or another suitable assessment tool.
• To assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.
• To provide co-ordination and navigation for people and their carers across health and care services, working closely with Social Prescribing Link Workers, Health and Wellbeing Coaches, and other primary care professionals, and support the co-ordination and delivery of MDTs within the PCN.
• To work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN.
• To raise awareness within the PCN of shared-decision making and decision support tools; and how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.
• To be able to plan and respond to workload according to operational priorities.
• To provide administrative support to the PCN team.
• To schedule the monthly MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
• To co-ordinate and manage the administrative functions of MDT meetings.
• To liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
• Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
• Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.
• Manage reporting required and associated within the Network DES specifications for required services.

Person Specification

• Professional attitude and assertive approach.
• Committed to development.
• Conscientious, hardworking and self-motivated to work with minimal supervision.
• Creative and tenacious in finding solutions to difficult problems.
• Ability to meet deadlines and work under pressure.
• Ability to engage and sustain relationships with all professionals, other organisations and service-users.
• Approachable and flexible.
• Honest and reliable.
• Sensitive to patients' needs.
• Demonstrate commitment to combatting disadvantage and inequality in health provision.
• Commitment to person-centred care.
• Demonstrate a willingness to participate in sharing the future of the PCN by taking on responsibilities and projects in addition to core workload.
• Forward thinker.
• Able to work in a changing environment.

Values, Drivers and Motivators

• Willingness to undergo further training and development.
• Requires a flexible approach and a need to be highly motivated.
• The role may need to be reviewed and developed in the future in line with changing priorities.

Other

• Flexibility to work outside of core office hours if required.
• Car user (to travel between more than one GP practice and other sites within the PCN geographical footprint).
• Car insured for business use.

Qualifications

• Educated to GCSE or equivalent.
• Evidence of further study/training.
• GCSE Grade C (or equivalent) in Maths and English.

Skills and Attributes

• Excellent written and verbal communication skills.
• Excellent interpersonal skills.
• Excellent knowledge of Microsoft Office.
• Able to deal with service users sensitively.
• Able to work as part of a team.
• Ability to work independently and prioritise own workload working on complex cases in a busy environment.
• Ability to work as a member of a multidisciplinary team.
• Excellent motivational and influencing skills.
• Strong analytical and judgement skills.
• Ability to analyse and interpret information and present results in a clear and concise manner.
• Excellent organisational and administration skills.
• Ensures completion of tasks on time and able to effectively influence others to complete agreed actions.
• Experience of providing advice/signposting to users.

Experience

• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
• Understanding of social determinants of health and how these can be addressed in regard to patient care.
• Sound understanding of disease prevention (primary, secondary and tertiary) and how patients can build prevention into their lifestyle.
• Minimum of 2 years experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field.
• Experience of electronic patients records.
• Experience of working in a patient-facing role.
• Experience of setting up meetings through Microsoft Teams or Zoom.
• Experience of data collection and providing monitoring information.
• Experience of working in a multidisciplinary setting where influence and negotiation is required.
• Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
• Experience of undertaking quality improvement activity.
• Awareness of local services and resources for individuals, carers and families.
• Knowledge/familiarity of medical terminology.

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.