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PCN Care Coordinator - Smethwick, United Kingdom - Lodge Road Surgery
1 week ago
Description
Job summary
Care coordinators play animportant role within a practice and the PCN to proactively identify and workwith people, including the frail/elderly and those with long-term conditions,to provide coordination and navigation of care and support across health andcare services.
Care coordinators help patientsnegotiate their way through the NHS and so can help them organise secondarycare follow up or appointments within the wider NHS. They will also coordinatecommunity care of complex patients after their admission to hospital. Their aimis to help people access the healthcare they need across all settings.
Main duties of the job
Care coordinators will attendmultidisciplinary team meetings within the practice and the wider PCN and willhave a central role in organising those meetings with the clinicians and ensureappropriate follow up for patients occur.
The successful candidate will bebased at Lodge Road Surgery, but will be expected to work within PCN practices when required.
They will be caring, dedicated,reliable and person-focussed and enjoy working with a wide range of people.They will have good written and verbal communication skills and strongorganisational and time management skills. They will be highly motivated andproactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.
Please note that the role of a care coordinator is nota clinical role
About us
Lodge Road Surgery is the Lead Practice for Central Health Partnership PCN. Our PCN has a total list size of around 58,000 patients across 7 practices in the West Midlands.
Job descriptionJob responsibilities
To provide direct support to the Social Prescribing and ClinicalPharmacy Role and provide a coordinated approach across the PCN memberpractices.Complete evaluation, efficiency and reporting of ARRS roles where required tomeet NHS/PCN guidelines.
To provide support to the Social Prescriber team in building outand supporting voluntary groups/organisations, develop content and maintainingthe accuracy of the Directory of Services.
Set up and managing a group for patients where the demand is notmet by CVS or local groups ( a walking group or coffee morning for thelonely).
Work with Clinical Pharmacist to facilitate group consultations care homepatient reviews and support the delivery of the Clinical Pharmacy requiredoutcomes.
Produce monthly news letters for the ARRs roles
Organise meeting, produce agendas and minute meeting for the SocialPrescribers, Clinical Pharmacists and other ARRs roles and the leadpractitioners.
Working with Individual Practice Clinicians and Practice Managers to beresponsible for the management of the coordination for the assessment ofLearning Disability Patients and other joint projects as needed.
tilise population health intelligence to proactively identifyand work with a cohort of patients to deliver personalised care;
support people to utilise decision aids in preparation for ashared decision-making conversation and to take up training and employment helpthem in accessing appropriate benefits where eligible
Work with people to bring together a single personalised careand support plan (PCSP), in line with PCSP best practice.
help people to manage their needs through answering queries,making and managing appointments, and ensuring that people have good qualitywritten or verbal information to help them make choices about their care. Offersupport to understand their level of knowledge, skills and confidence (theirActivation level) when engaging with their health and wellbeing, includingthrough the use of the Patient Activation Measure;
assist people to access self-management education courses, peersupport or interventions that support them in their health and wellbeing and increasetheir activation level. Explore and assist people to access personal healthbudgets where appropriate;
work with the GPs and other primary care professionals withinthe PCN to identify and manage a caseload of patients, and where required andas appropriate, refer people back to other health professionals within the PCN;
To co-ordinate recall lists forpatients who are being monitored for chronic health conditions
Identify unpaid carers and helpthem access services to support them.
Conduct follow-ups oncommunications from out of hospital and in-patient services.
To follow up patients who havebeen discharge from hospital to ensure all discharge actions have been carriedout and to identify any additional needs to reduce the risk of readmission.
Support practices to keep carerecords up to date by identifying and updating missing or out-of-dateinformation about the persons circumstances.
Person SpecificationQualifications
Essential
Desirable
Experience
Essential
Desirable
