PCN Care Coordinator - Frailty / Learning Disability

at  Stalybridge Denton Glossop PCNs

Purpose of the role Care co-ordinators play an important role within a PCN to proactively identify and work with people, including the frail, elderly, people with Learning Disability and those with long-term conditions, to provide co-ordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to people and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. Care co-ordinators could provide time, capacity and expertise to support people in preparing for, or following-up, clinical conversations.
Enabling them to be more actively involved in managing their care and supporting them to make choices that are right for them. Care co-ordinators help people improve their quality of life. The successful candidate will be based in Stalybridge, Dukinfield & Mossley PCN. They will be caring, dedicated, reliable, person-focussed and enjoy working with a wide range of people.
They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive 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. This role is an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers, Cancer Care Coordinator, Mental Health Nurse amongst other roles to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN. Key responsibilities Work with people, their families and carers, to improve their understanding of their condition.
Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health. Provide co-ordination and navigation for people and their carers across health and care services.
Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN. Support the co-ordination and delivery of multidisciplinary teams with the PCN. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations.
Explore and assist people to access a personal health budget where appropriate. Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours. Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies. Identify carers and help them access services to support them.
Conduct follow-ups on communications from out of hospital and in-patient services. Maintain records of referrals and interventions to enable monitoring and evaluation of the service. Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances. Contribute to risk and impact assessments, monitoring and evaluations of the service.Key tasks Enable access to personalised care and support.
Take referrals or proactively identify people who could benefit from support through care co-ordination. Have a positive, empathetic and responsive conversations with people and their families and carer(s), about their needs. Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them.
Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly. Support people to develop and implement personalised care and support plans. Review and update personalised care and support plans at regular intervals. Support people to develop and implement Advanced Care Plans Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
Work as part of a home visiting phlebotomy service.Co-ordinate and integrate care Make and manage appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system. Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a co-ordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
Actively participate in multidisciplinary team meetings in the PCN. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. Record what interventions are used to support people, and how people are developing on their health and care journey. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care co-ordination on their health and wellbeing. Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.Supervision/professional development Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Access relevant GPs to discuss patient related concerns, and be supported to follow appropriate safeguarding procedures;Miscellaneous Establish strong working relationships with GPs and practice teams and work collaboratively with other care co-ordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team. Act as a champion for personalised care and shared decision making within the PCN. 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 PCNs policies and procedures. Contribute to the wider aims and objectives of the PCN to improve and support primary care

Please refer the Job description for details