Care Coordinator

Key Responsibilities • Manage patient signposting and referral for services within the various practices. • Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance. • Proactively participate in health promotion and screening programmes for patients. • Identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids. • Undertake work in line with PCN directed priorities. • Work closely with the Clinical Director, Strategic and Operations Director, Practice Managers, GPs and other staff within the various PCN practices to deliver the numerous workstreams under the PCN contract. • Proactively identify (using population data) patients with long-term conditions and support their personalised care needs, including preparing for shared decision-making conversations and providing holistic support. • Help patients manage their needs by answering queries, making and managing appointments, ensuring good quality written or verbal information is available to support informed choices, and acting as the first point of contact for patients within the caseload. • Assist with patient queries, signposting, facilitating access to self-management education, peer support, interventions, and support patients to take more control of their health and wellbeing. • Assist patients to access personal health budgets where appropriate. • Provide coordination and navigation for people and their carers across health and care services, working closely with primary care professionals, social prescribing link workers and partner agencies. • Promote and support PCN health initiatives, including immunisations, NHS Health Checks, cervical screening, breast screening, bowel screening, and other national screening programmes. • Proactively support call and recall processes and coordinate immunisation campaigns, including childhood immunisations and flu vaccinations. • Support the coordination and delivery of multidisciplinary team (MDT) working and discussions within the practice, neighbourhood and PCN, including organising MDT meetings, identifying issues for discussion, liaising with GPs, pharmacists, nursing teams, care homes and other agencies, and circulating relevant information. • Raise awareness of shared decision-making, decision support tools, health promotion and NHS Health Checks within practices. • Support Quality and Outcomes Framework (QOF), enhanced services and contractual specifications. • Review treatment programmes that promote health and wellbeing. • Coordinate specified clinics, liaising with schedulers and contacting identified patients with appointments. • Manage patient-initiated calls for help or signposting, booking patients into named GP urgent care or telephone slots where appropriate. • Document and monitor aspects of patient coordination and service delivery, supporting data collection and audit using the patient administration system. • Demonstrate the ability to recognise and respond appropriately to sudden deterioration or emergency situations, alerting the team or enabling a rapid response. • Monitor referrals to ensure tasks are completed and care delivered by maintaining regular telephone contact with patients and partner agencies. • Refer patients to PCN Social Prescribing Link Workers where appropriate. • Bring together all identified care and support needs into a single Personalised Care and Support Plan (PCSP), in line with best practice. • Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, and support them to access training, employment and appropriate benefits where eligible. • Organise and prioritise own workload, working independently and as a committed member of the multidisciplinary team. Depending on work plans, there may be a requirement to work across different groups and teams. • Support patient and carer contact roles and collate patient and carer feedback on their experiences. • Maintain and develop engagement with all practice staff and encourage best practice. • Understand that this role profile is not exhaustive, and you may be directed to complete other reasonable duties according to the skills and requirements of the role. ConfidentialityIn the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information relating to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients, carers, practice or staff information. All such information, from any source, is to be regarded as strictly confidential. Information relating to patients, carers, colleagues or member practices may only be disclosed to authorised persons in accordance with PGPA policies and procedures relating to confidentiality and the protection of personal and sensitive data, or under the guidance of your manager. Job description Job responsibilities Key Responsibilities • Manage patient signposting and referral for services within the various practices. • Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance. • Proactively participate in health promotion and screening programmes for patients. • Identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids. • Undertake work in line with PCN directed priorities. • Work closely with the Clinical Director, Strategic and Operations Director, Practice Managers, GPs and other staff within the various PCN practices to deliver the numerous workstreams under the PCN contract. • Proactively identify (using population data) patients with long-term conditions and support their personalised care needs, including preparing for shared decision-making conversations and providing holistic support. • Help patients manage their needs by answering queries, making and managing appointments, ensuring good quality written or verbal information is available to support informed choices, and acting as the first point of contact for patients within the caseload. • Assist with patient queries, signposting, facilitating access to self-management education, peer support, interventions, and support patients to take more control of their health and wellbeing. • Assist patients to access personal health budgets where appropriate. • Provide coordination and navigation for people and their carers across health and care services, working closely with primary care professionals, social prescribing link workers and partner agencies. • Promote and support PCN health initiatives, including immunisations, NHS Health Checks, cervical screening, breast screening, bowel screening, and other national screening programmes. • Proactively support call and recall processes and coordinate immunisation campaigns, including childhood immunisations and flu vaccinations. • Support the coordination and delivery of multidisciplinary team (MDT) working and discussions within the practice, neighbourhood and PCN, including organising MDT meetings, identifying issues for discussion, liaising with GPs, pharmacists, nursing teams, care homes and other agencies, and circulating relevant information. • Raise awareness of shared decision-making, decision support tools, health promotion and NHS Health Checks within practices. • Support Quality and Outcomes Framework (QOF), enhanced services and contractual specifications. • Review treatment programmes that promote health and wellbeing. • Coordinate specified clinics, liaising with schedulers and contacting identified patients with appointments. • Manage patient-initiated calls for help or signposting, booking patients into named GP urgent care or telephone slots where appropriate. • Document and monitor aspects of patient coordination and service delivery, supporting data collection and audit using the patient administration system. • Demonstrate the ability to recognise and respond appropriately to sudden deterioration or emergency situations, alerting the team or enabling a rapid response. • Monitor referrals to ensure tasks are completed and care delivered by maintaining regular telephone contact with patients and partner agencies. • Refer patients to PCN Social Prescribing Link Workers where appropriate. • Bring together all identified care and support needs into a single Personalised Care and Support Plan (PCSP), in line with best practice. • Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, and support them to access training, employment and appropriate benefits where eligible. • Organise and prioritise own workload, working independently and as a committed member of the multidisciplinary team. Depending on work plans, there may be a requirement to work across different groups and teams. • Support patient and carer contact roles and collate patient and carer feedback on their experiences. • Maintain and develop engagement with all practice staff and encourage best practice. • Understand that this role profile is not exhaustive, and you may be directed to complete other reasonable duties according to the skills and requirements of the role. ConfidentialityIn the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information relating to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients, carers, practice or staff information. All such information, from any source, is to be regarded as strictly confidential. Information relating to patients, carers, colleagues or member practices may only be disclosed to authorised persons in accordance with PGPA policies and procedures relating to confidentiality and the protection of personal and sensitive data, or under the guidance of your manager.