Purbeck PCN Digital & EHCH Care Coordinator

at  Purbeck Primary Care Network

CARE COORDINATOR RESPONSIBILITIES & DUTIES Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. Support patients to utilise decision aids in preparation for a shared decision-making conversation. Holistically bring together all a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care, using tools to understand peoples level of knowledge, confidence in skills in managing their own health.
Support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers. Assist people to access self-management education courses, peer support or interventions that support them to take more control of 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, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals.
Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN. Raise awareness within the PCN of shared decision-making and decision support tools. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations. DIGITAL RESPONSIBILITIES & DUTIES The Digital Care Coordinator responsibilities & duties may include any or all of those listed below.
Duties may vary from time to time under the direction of the PCN Leadership team, dependent on current and evolving PCN priorities and workstreams. Work closely with PCN colleagues to identify patients who currently do not use digital channels for healthcare access, promoting digital inclusion and encourage the wider use of the NHS App. Use available data sources to help the multidisciplinary teams understand the health and well-being profiles of our residents and to identify specific groups of patients and arrange care for them. This will include undertaking searches to identify individuals who meet particular criteria, for example patients requiring blood pressure monitoring.
Assist the PCN to deliver improvements to the services we provide our patients with relevant data and data analysis. Support the PCN with coding activity appropriately and develop reports to demonstrate PCN activity. Assist the PCN member practices to engage with hard-to-reach populations and to reduce health inequalities. Take a lead in the deployment of new technologies and education of patients.
Run regular proactive reports to identify patients who may benefit from new services/new ways of delivering services and ensure appropriate referrals are made. Work with colleagues and partner organisations to promote digital inclusion, for example, by demonstrating to and educating colleagues about how to optimally use digital technologies and data/intelligence. Support the PCN Administrator to develop social media content for the PCN including website, Facebook - promoting ARRS roles, services and health campaigns. Providing data administration support to the PCN Leadership team and member practices as required.
Any reasonable requests from the PCN Leadership team. Act as an ambassador for use of digital healthcare technology with both patients and colleagues. Support PCN and member practices with handling and analysing data and developing our digital maturity. Support partner practices to maintain and monitor data coding and quality on clinical systems, ensuring coding is compliant and consistent.
Run system reports and extract data as required by the PCN for activity reporting, using SystmOne clinical system, PCN digital dashboard and other data sources. Be a point of contact for digital enquiries and be an active member of the NHS Dorset Digital CoP. Under the direction of the PCN Leadership team, support the implementation of digital projects across the PCN and member practices. EHCH RESPONSIBILITIES & DUTIES You will work closely with the EHCH Advance Nurse Practitioner to manage patient lists for the upcoming days/weeks, ensuring contingency plans are in place and followed for unexpected leave.
Liaise directly with care homes for non-clinical tasks such as booking and managing ward round lists for clinical staff within the PCN SystmOne module. Upon request you will provide patient lists to the EHCH Advance Nurse Practitioner in advance of planned visits for monthly GP ward rounds. Managing the EHCH inbox daily and dealing with requests in a timely manner. You will be required to follow a SOP for referral requests and need to deal with non-clinical enquires the care homes may have.
You will also be required to send confidential and encrypted emails at times. You will be responsible for escalating clinical enquiries to the EHCH Advance Nurse Practitioner in a timely manner. Responsible for registering new care home patients as per the SOP in Practice SystmOne modules. If required, arrange the weekly MDT meeting on behalf of the EHCH Advance Nurse Practitioner.
Produce reports such as, but not limited to; care home bed capacity numbers, monthly clinician appointment numbers and anything else requested by the EHCH Advance Nurse Practitioner

Please refer the Job description for details