Primary Care Network Care Coordinator

at  Lakeside Healthcare Group

Care coordinators provide extra time, capacity, and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the PCN to better identify and manage a caseload of selected patients making sure that appropriate support is made available to them and their carers and ensuring that their changing needs are addressed. They focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification, this will include support digital referral management, for example from the NHS App. You will have a background in healthcare coordination, an understanding of projects and population health initiatives.
In this role, you will be responsible for managing and coordinating care services, collaborating with multidisciplinary teams, and implementing processes to improve health outcomes for specific populations. You will play a crucial role in the success of our population health project and contribute to enhancing the overall well-being of our community. Key responsibilities and tasks You Will: Support and contribute to the population health project. Collect, analyse and interpret data related to population health, identifying trends, gaps in care and areas for improvement.
Support project plans, timelines and milestones to ensure the successful execution of population health initiatives. Maintain accurate and up-to-date records of patient interactions, interventions, and outcomes, and generate reports to monitor project progress and outcomes. Stay informed about the latest developments in population health and apply this knowledge to improve project effectiveness. Proactively identify and work with a cohort of people to support their personalised care requirements, ensuring an understanding of what matters to them.
Bring together all of a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice. Help people to manage their needs, answering their queries and supporting them to make appointments. Support people to take up training and employment, and to access appropriate benefits where eligible. Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision making conversation.
Ensure that people have good quality information to help them make choices about their care. Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through use of the Patient Activation Measure. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Explore and assist people to access personal health budgets where appropriate.
Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. Support the coordination and delivery of Multi Discipline Teams within PCNs. Support the management of referrals received through the NHS App to the practice and direct to the appropriate clinician or professional group. Liaise with members across all practices within the PCN, supporting good communication.
Refer through to the appropriate member of the team, and/or make referrals on behalf of the team. Support the co-ordination and delivery of multidisciplinary teams (MDTs) within the PCN, to include management and arrangement/planning of team meetings and producing reports as requested. Visit patients in community, home or care home setting to assess and discuss their care needs involving carers, as appropriate. Establish good working relationships with people employed in practices across the PCN to enable them to carry out their duties effectively.
It is important that the skills of existing teams continue to be valued and their roles developed as agreed with the practice. Training requirements: The Personalised Care Institute will set out what training is available and expected for Care Coordinators. Other Be willing to undertake travel to various locations to carry out duties of the post as required. To safeguard the health, well-being, and safety of the patients we work with, some of whom maybe classed as vulnerable people or adults at risk.
In the event of a risk to a Patient becoming apparent or if concerns arise about a vulnerable persons welfare, to immediately report these concerns in line with the appropriate policy and procedure. NB. in addition to these responsibilities, employees are required to carry out other duties as may be reasonably required. Lakeside Healthcare reserves the right to vary this job description from time to time in line with business needs

Please refer the Job description for details