Pcn Care Coordinator - Skelmersdale, United Kingdom - OWLS CIC

Description

Job summary
An exciting opportunity has arisen for a Care Co-ordinator to develop a pioneering role within primary care.

The role will 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 roles.

West Lancashire GP Federation is looking for a Care Co-ordinator to join the Skelmersdale PCN. There are 6 member practices of Skelmersdale PCN who cover a population of 55,000 patients.


Main duties of the job

Care Co-Ordinators provide extra time, capacity and expertise to support patients in preparing for or in following up clinical conversations that they have with primary care professionals i.e.

doctors, nurses, physiotherapists, physician associates, paramedics etc.

Their focus is on delivering a comprehensive model for personalised care, reflecting local priorities, health inequalities and population health management risk stratification.

They also support the coordination and delivery of MDTs within PCNs.

You will take an approach that is non-judgmental, based on strong communication and negotiation skills.

Your role and skills will support and encourage the prevention of developing further illness, or the deterioration of existing long-term conditions.

When working with our local care homes, the role will focus on undertaking a personal care and support plan for each resident and sign posting patient needs to fellow Enhanced Care Home Scheme Team members.

About us
Employment will be with the West Lancashire GP Federation as a central function to the Primary Care Network members.

Direct line management and will be provided by the Primary Care Network Manager and wider team of GPs, local CCG Medicines Optimisation team, Practice Managers and Advanced Nurse Practitioners.

Job responsibilities

Care Co-Ordinators will:
- work closely with practice and PCN healthcare roles, the PCC is to identify and work with a cohort of people to support their personalised care requirements, using any available decision support tools such as Patient Activation Measure (PAM), templates and software
- collate all of a patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice
- meet patients, patient carers and family members to discuss their personalised care requirements, the services available to them and the help they want
- visit patients, checking on the care that they have received and documenting it accordingly
- work with the care team to evaluate interventions and identify where and when further ones will be required
- help people to manage their needs by answering their queries and supporting them in making appointments
- support people to access appropriate benefits where eligible as well as taking up employment and training
- assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools
- provide patients with high quality, easy to understand information to assist them in making choices about their care
- support patients in understanding their level of knowledge, skills and confidence (known as activation level) when participating in their health and well-being using, where appropriate, the PAM
- liaise with other PCCs in other practices across the region and share best practice
- assist patients to access self-management education courses, peer support or interventions that support them in their health and well-being
- where appropriate, to assist patients to access personal health budgets
- provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW)
- support in the delivery of enhanced services and other service requirements on behalf of the PCN
- lead in the management of patient complaints and participate in the identification of any necessary learning brought about through clinical incidents and near-miss events
- actively participate in the delivery of multi-disciplinary team (MDT) meetings within PCNs; responsible for preparatory admin, sending meeting invitations and taking notes of meetings.
- undertake all mandatory training and induction programmes
- contribute to and embrace the spectrum of clinical governance
- contribute to public health campaigns (e.g. flu clinics) through advice or direct care

• Undertaking clinical observations to support the plans, as appropriate.
• Engage with and support the new and evolving agendas and service requirements across the PCN, including our work with Care Homes residents and the need to proactively manage their care in an individualised way.

Person Specification

Qualifications

Essential

• Minimum English GCSE gr