PCN Care Coordinator in Ruislip

This role requires the post holder to work on-site with no home working. The job location listed on this vacancy is the company address of The Confederation Hillingdon CIC. An exciting opportunity has arisen within Primary Care for a Care Coordinator at The Confederation, Hillingdon CIC based at our Colne Union PCN in Yiewsley / West Drayton. We have 1 full-time vacancy available on a permanent contract.

The practices that this PCN covers include:

• The Green Medical Centre
• The High Street Practice
• Yiewsley Family Practice
• Otterfield Medical Centre
• Oakland Medical Centre

Care Coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to people and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.

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

Main duties of the job

We recognise the value that a PCN Care Coordinator can bring to our practices and our aim is to provide exemplary patient care; finding innovative solutions in general practice to deliver the best outcomes to our patients. We are seeking an enthusiastic and forward-thinking PCN Care Coordinator to join the ever-growing team. The role will be to work within our network of GP Practices to provide a central co-ordination role for patient care planning.

Job responsibilities

• Work with people, their families and carers, to improve their understanding of their condition.
• Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
• Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
• Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.
• Provide coordination and navigation for people and their carers across health and care services.
• Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload.
• Support the coordination and delivery of multidisciplinary teams with the PCN.
• Raise awareness of how to identify patients who may benefit from shared decision making.
• Take referrals or proactively identify people who could benefit from support through care coordination.
• Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
• Develop an in-depth knowledge of the local health and care infrastructure.
• Use tools to measure people's levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.
• Review and update personalised care and support plans at regular intervals.
• Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person's care.
• Make and manage appointments for patients, related to primary care.
• Help people transition seamlessly between secondary and community care services.
• Refer onwards to social prescribing link workers and health and wellbeing coaches where required.
• Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the person's care.
• Actively participate in multidisciplinary team meetings in the PCN.
• Identify when action or additional support is needed.
• Record what interventions are used to support people, and how people are developing on their health and care journey.
• Work with your supervising GP and/or line manager to undertake continual personal and professional development.
• Establish strong working relationships with GPs and practice teams.
• Act as a champion for personalised care and shared decision making within the PCN.
• Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required.
• Identify opportunities and gaps in the service and provide feedback to continually improve the service.
• Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities.
• Adhere to organisational, practices and PCN policies and procedures.
• Contribute to the wider aims and objectives of the PCN to improve and support primary care.

Person Specification

• GCSE in English and Maths.
• IT literacy.
• Experienced Care Coordinator with EMIS experience.
• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities.
• Ability to communicate effectively, both verbally and in writing.
• Ability to identify risk and assess/manage risk when working with individuals.
• Ability to maintain effective working relationships and promote collaborative practice.
• Ability to demonstrate personal accountability, emotional resilience and work well under pressure.
• Ability to organise, plan and prioritise on own initiative.
• Demonstrable commitment to professional and personal development.
• Proficient in MS Office and web-based services.
• Excellent interpersonal, influencing and negotiating skills.
• Excellent written and verbal communication skills.

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.

£25,000 to £33,000 a year, dependent on experience.