Care Coordinator - Bristol, United Kingdom - 4PCN

Description

4PCN (Primary Care Network)

Hanham Health, Kingswood Health Centre, Cadbury Heath Health Centre and Close Farm

Care Coordinator - Job Description

Reporting to:
PCN Operations Manager/PCN Manager


Hours: 37.5 hours per week


Salary:
£12.18 per hour rising to £12.86 per hour once training and probation period is completed satisfactorily


Base:
Based at Kingswood Health Centre, but travel within the PCN area is required


Job Overview

Care co-ordinators provide extra time, capacity, and expertise to enable patients with enhanced needs to access the services and support they require to improve their health and wellbeing, helping to improve their quality of life and reducing health care inequalities.

They ensure these patients, and their carers have access to good quality information to help them make informed choices about their care.

They proactively identify and liaise with an identified cohort of patients to support their personalised care requirements, making sure that the appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.

The Care co-ordinators work with groups of patients identified by local priorities, health inequalities or using population health management risk stratification.

At present the current focus is on patients with learning disabilities (LD), adults with severe mental illness (SMI) and adults looking to engage with weight loss services, but other groups will also form part of the post holders work plan.

You will proactively organise and complete health check appointments for patients where appropriate, either in their own homes or at their practice, providing them with tools to best prepare them for shared decision making conversations.

This may include gathering information directly or providing information to the patient and/or carer.

You will help patients and their carers by being a point of contact/advocate.

With your support, it is hoped patients will navigate or signpost effectively for their health needs and ensure they have excellent good quality written and verbal information.

This may take the form of being the link between the practice, the multi-disciplinary team, or the wider healthcare community, or signposting towards services such as social prescribing, OneYou South Gloucestershire etc.

Supporting People with Learning Disabilities

• You will liaise with practice teams to ensure that there is a proactive call and recall system for patients 14 years of age and over with learning disabilities, booking and completing their annual health check, including taking any blood tests, blood pressure checks, height and weight measurements as required. Also providing information to help them get the most from their review.
• You will proactively engage with these patients, carers and the practices to ensure maximum uptake of these reviews and follow up any patients who fail to attend their appointments.
• You will ensure that contacts with the patient are recorded appropriately and that checks are coded and recorded accurately.
• You will act as a link between Support Workers, the GP and any PCN, primary, community or secondary care colleagues, supporting any onward referrals, care planning or administrative patient needs as appropriate.

Serious Mental Illness Reviews

• You will liaise with practice teams to ensure there is proactive call and recall system for patients with Severe Mental Illness, booking and completing their mental health review, including taking any blood tests, blood pressure checks, height and weight measurements as required.
• You will proactively engage with these patients, carers and the practices to ensure maximum uptake of these reviews and follow up any patients who fail to attend their appointments.
• You will ensure that contacts with the patient are recorded appropriately and that checks are coded and recorded accurately.
• You will act as a link between Support Workers, the GP and any PCN, primary, community or secondary care colleagues, supporting any onward referrals, care planning or administrative patient needs as appropriate.

Weight Management Services

• You will be the PCN administrative lead for these services, identifying suitable patients and making contact in the first instance.
• You will be involved in discussions with patients to determine how motivated they are to engage with services.
• You will book appointments and make referrals as appropriate and may be required to gather baseline information (such as height, weight etc) as per the protocols for these services.
• You will ensure that contacts with patient are recorded appropriately and that checks are coded and recorded accurately.

General Duties

• You will ensure safeguarding issues or patient related concerns are raised appropriately to a suitable individual.
• You will help administratively with any auditing or searching of GP clinical systems.

This job descrip