Main Role and Responsibilities To work as a team of Vulnerable Patient Care Coordinators, with the GPs and other primary care professionals within the PCN to proactively identify and support some of our most vulnerable patients who require additional input due to their presentation. The focus being those patients with learning disabilities, those on the safeguarding register, those with diagnosis of cancer and to support with cancer screening uptake as well. Be flexible to work collaboratively and support the other care coordinator teams across the PCN with work that is required as directed by the PCN management team. In some cases, especially when working with patients with learning disabilities, to visit these patients in their own homes or see them within the practice where appropriate to complete a holistic review of the patients health and social needs following an agreed assessment pathway.
Data collection and submission, filing, general admin etc. Bring together all a persons identified care and support needs and what matters to them; explore the options to address these in a single personalised care and support plan created in collaboration with the patient and their family as appropriate. Communicating at least monthly with the PCN management team about ongoing workstreams and work completed. Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation.
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. Support the coordination and delivery of multidisciplinary teams within PCN, in particular working with the PCN Pharmacy team. Provide coordination and navigation for individuals and their carers across health and care services, working closely with social prescribing link workers and other roles such as social services, school nurses, health visitors and midwives. To help patients to manage their needs through answering queries, making, and managing appointments Assist and coordinate practices in meeting PCN DES, Locally Commissioned Service Targets and Impact and Investment Fund (IIF) targets, and practice Quality Outcomes Framework (QoF) targets.
Promote vaccination, screening and health improvement across patient groups Work closely with GPs, nurses, social prescribers and external agencies to ensure coordinated care. The role includes working together as a team of care coordinators to support the below groups of patients. Some aspects of the role are indicated under each heading. 1.
Learning Disabilities (LD) Maintain and update LD registers, ensuring accurate coding and data. Coordinate and promote annual LD health checks. Liaise with GPs and nurses to allocate patients and schedule appointments in the correct order (care coordinator nurse GP). Complete pre-health check reviews using the Ardens LD template Promote vaccinations (MMR, flu, COVID) and cancer screening.
Liaise with community and childrens LD teams when appropriate. Act as a point of contact for LD patients and carers for navigation and support. 2. Safeguarding Maintain and update adult and child safeguarding lists for aligned practices.
Organise and minute bi-monthly safeguarding meetings, documenting outcomes in EMIS. Complete Child Protection Case Conference reports using EMIS templates and submit via the agreed process. Contact and support families of children awaiting CAMHS, offering signposting and welfare checks. Monitor and respond to DNAs for vulnerable children and adults, using appropriate templates and flagging concerns.
Liaise with safeguarding leads and attend multi-agency meetings as appropriate. Support the welfare of parents’ mental health when capacity allows, using structured check-ins and signposting. 3. Cancer Care Coordination Conduct and document 3-month and 12-month cancer care reviews.
Maintain the Gold Standards Framework (GSF) register and ensure care plans/DNACPR status are documented and uploaded to EPAACs. Organise and minute monthly GSF meetings with practices, involving DNs/Macmillan as required. Promote cancer awareness campaigns and screening programmes (smear, bowel, breast) across practices and actively follow up patients who have refused or not responded to screening invitations. Support PCN audit work on cancer diagnoses to identify improvement opportunities for early diagnosis.
Monitor DNAs for cancer and frail patients, identifying barriers and supporting re-engagement. 4. ED attendances and DNAs Monitor DNAs for vulnerable patients, contacting patients/carers, identifying barriers, and supporting re-engagement. Monitor A and E attendances in under 18s, contacting families when appropriate to discuss alternatives to ED, health needs, and safeguarding concerns.
Use Ardens templates consistently to document contacts and interventions. It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role to meet the needs of our patients in an ever changing healthcare environment

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