Care Co-ordinator - Beverley, United Kingdom - Beverley PCN Limited

Description

Primary Care Network Care Coordinator Job Description

Primary Care Network:
Beverley


Accountable to:
PCN Clinical Director and PCN Chief Operating Officer

Professionally accountable to:
PCN Chief Operating Officer


Salary:
Equivalent to AFC band 4


Job Summary
This is a really important and pivotal role within Beverley PCN. You need to be a strong decision maker and know how to challenge appropriately.

You would benefit from having wider clinical knowledge to aid with the decision making process in order to ensure the standard of care delivered meets the expected requirements.

Care coordinators play an important role. You work with a team of ACP's, FCP's and Paramedics.

You coordinate the work of the PCN Team to provide care and support across the PCN's care and residential homes (and wider as required) within the 4 member practices area.

You will work closely with the PCN team and with the practice teams, acting as a central point of contact to the care homes and selected cohorts of patients to ensure appropriate support is made available via the PCN Team.

This is achieved by planning and organizing the care required for each patient and ensuring that this is delivered in the most effective and proactive way.

You will be bringing together all the information about a person's identified care and support needs and exploring options with the PCN team for them to meet these within a single personalised care and support plan, based on what matters to the person.

Some project work will be undertaken, where a focus is on a particular demographic of the patient population.

Care coordinators review patients' needs and assist with access to other services such as, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.

This role is an integral part of the PCN's multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

There may be a need to work remotely depending on the requirements of the role.


Primary Duties and Areas of Responsibility

• Organise the workload of the PCN team to meet the requirements of the DES.
• Work with the management of Care Homes to ensure compliance with data recording.
• Ensure that service levels to the Care Home population are maintained and meet specific targets in relation to QoF and IIF.
• Work collaboratively with the PCN team and other primary care professionals within the PCN to proactively identify and manage a workload, which may include patients with longterm health conditions, and where appropriate, refer back to other health professionals within the PCN.
• Refer onwards to social prescribing link workers and health and wellbeing coaches where required;
• Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
• Keep accurate and uptodate records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation;
• Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
• Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner;
• Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning;
• Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities;
• Work in accordance with the practices' and PCN's policies and procedures;
• Contribute to the wider aims and objectives of the PCN to improve and support primary care.

Key Relationships

Key Working Relationships:

• PCN Team of FCP, ACP's and Paramedics
• Beverley PCN Manager
• GPs and General practice teams within the PCN
• PCN Clinical Director
• Multidisciplinary team.

members including but not exhaustive:
Clinical Pharmacists, technicians, Physician Associates, Physios, Paramedics, Social Prescribing Link Workers, Care coordinators.

• OHP clinical and nonclinical staff.
• GP practice and multidisciplinary teams from neighbouring PCNs

Special Working Conditions

• The postholder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies.

Job Description Agreement

Personal/Professional development:

• The postholder will participate in any training programme required by the PCN and P