PCN Care Coordinator

at  Hope Citadel Healthcare CIC

Main Duties and Responsibilities Help people to manage their needs through answering queries, and ensuring that people have good quality written or verbal information to help them make choices about their care. Own a list of potential patients across the PCN practices who are over 65 with mild and moderate frailty. Contact patients on the list to enrol them in the programme and triage them into a pathway depending on their response to a questionnaire, working closely with an Advanced Nurse Practitioner. Support the ongoing case management of patients on this pathway through regular check-ins and respond to any significant events (e.g.
hospital admission), as well as supporting them to ensure their patient-centred care plan is regularly reviewed. Work closely with multiple professionals from across the sectors to coordinate the patients care and ensure they are receiving the help and support they need. Support the PCN on implementation of the programme by working within governance structures and providing feedback and iteration of the model. Maintain a log that records the journey of each patient on the PHM programme, including the services they are referred to.
Identify where there may be health inequalities and provide feedback on where engagement could be enhanced. Support improvement of information recording on patients across the PCN, including coding for these patients in EMIS and the Manchester Shared Care Record Work closely with care coordinators across other Oldham PCNs e.g. South and North who are implementing PHM pathways focussed on frailty to support integration of care across organisational boundaries. RESPONSIBILITIES TO PCN TEAMS Actively develop effective working relationships and lines of communication within the practice, with the PCN, and with wider multi-professional teams across South e.g.
Social Prescribers, Pharmacists and other clinical/non-clinical partners involve in the patients care Demonstrates ability to work effectively as a member of a team with the practice, PCN and ANP as a key person within the PHM model. Can recognise personal limitations and refer to more appropriate colleagues when necessary. Follow through with service users and others involved to ensure all services and care arrangements are in place. Develops an in-depth knowledge of local health and care infrastructure and knows how and when to enable people to access support and services that are right for them.
RESPONSIBILITIES TO PATIENTS Manage a caseload of patients with mild and moderate frailty within the PCN. Support patients to utilise decision aids in preparation for a shared decision-making conversation. Proactively checks in with patients on the case load to help manage their needs through answering queries and ensuring that people have good quality written or verbal information to help them make choices about their care. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing

Please refer the Job description for details