PCN Cancer Care Coordinator

at  James Alexander Family Practice

Duties and responsibilities: Coordinate and integrate care Act as a central point of contact for both patients and practice staff in relation to cancer care and support. Help people transition seamlessly between primary, secondary and community care services, supporting people to navigate through the wider health and care system. Identify all of a persons care and support needs and explore options together, to meet these within a single personalised care and support plan (PCSP), based on what matters to the person. Ensure personalised care and support plans are communicated to the GP practice and any other professionals involved in the patients care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED/READ codes.
Screening Develop and embed systems across the PCN to improve cancer screening uptake. This will include working alongside practices to develop and embed processes to track and follow up screening non-attenders. Support practices to evaluate their screening uptake and engage hard to reach populations to participate in screening, in order to reduce health inequalities. Work with the PCN Member practices to implement a range of activities and implement systems to improve patient uptake of cancer screening programmes including health events, group consultations etc Work collaboratively with local screening teams and the wider support services to increase uptake and follow up non-attenders/responders.
Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. Hard to Reach Groups Engage with and form strong working relationships with local community groups, particularly those that support those patients that are considered hard to reach. Support practices in identifying patients that require additional language/communication/cultural support in attending for screening, cancer care reviews or general medical services. Establish relationships with the voluntary sector and local support groups to understand cultural differences within the local population and to break down communication barriers to enable practices to provide further support/reassurance in relation to screening and cancer support.
Non-Clinical Cancer Care Reviews Work alongside the Strategic Manager, Clinical Director, Lead Care Coordinator and Member Practices to develop a non-clinical approach to cancer care reviews and to embed a process, ensuring proactive monitoring and tracking of patients suspected or confirmed of having a cancer diagnosis. Undertake non-clinical cancer care reviews, ensuring a personalised, holistic approach, tailored to the needs of the patient and their families/carer. Proactively work with other organisations, including, but not limited to, Hull PCNs, the Local Authority, MacMillan and the Cancer Alliance to explore ways of increasing access to groups in the area, particularly those that support prehabilitation and green social prescribing. Work collaboratively with the PCN Health & Wellbeing team, including the social prescribers, to support patients in being as healthy as possible during and post treatment.
Work collaboratively with the PCN social prescribing team to support patients in gaining access to social support including finance, employment, housing etc. Work with other Care Coordinators to develop knowledge of local services and teams, supporting and assisting each other through sharing of knowledge and good practice. Communication Recognise the roles of other colleagues within the organisation and their role to patient care. Use appropriate communication to gain the co-operation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals, other NHS/private organisations e.g.
ICBs). Work as a member of a team. Recognise personal limitations and refer to more appropriate colleague(s) when necessary. Actively work toward developing and maintaining effective working relationships both within and outside the practices/PCN and locality.
Foster and maintain strong links with all services across the locality. Explore the potential for collaborative working and take opportunities to initiate and sustain such relationships. Liaise with stakeholders (as identified in Key Working Relationships) to ensure consistency of patient care and benefit. Attend weekly Health & Wellbeing MDTs, actively participating and offer support/guidance.
Raise awareness of cancer screening programmes and the importance of cancer care reviews across the PCN and its Member Practice

Please refer the Job description for details