Care Co-ordinator Moorlands Rural PCN inAll Practices Within the PCN inAll Practices Within the PCN PUBLISHED 3 DEC 2023

Administrative Responsibilities
:

• 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
• To work as a key member of the MDT to help support the development of effective MDT meetings.
• Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers.
• To ensure that action points identified within the MDT are recorded and followed up
• Under guidance from their line manager, take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team
• To cross reference the patients identified as high risk with the carers register within the practice to support case managers and key workers in developing holistic anticipatory care plans including prevention of carer breakdown
• To work with the wider MDT to identify appropriate case managers for high-risk patients to ensure that patients are reviewed, and anticipatory care plans are developed
• Ensure that all patients Care Plans, diagnostics results, and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available
• To liaise with acute hospitals, cross referencing admission data with the at risk list and coordinating the sharing of key information between the acute hospital teams and the community services.
• Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute / community hospital setting

Personal/Professional development:

Participate in any training programme implemented by the PCN as part of this employment, such training to include:

Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development

Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

To work in accordance with health and safety policies and procedures including reporting and recording any health and safety incident or accident

Adhere to host employers adult and children safeguarding policies and procedures

This job description is not exhaustive, and duties may vary with the requirements of the PCN

Due to the current

Coronavirus (COVID-19) the NHS has had to adjust to new ways of working which may affect initially the way you undertake the job.

To work closely with the GP surgery teams, Primary Care Network Teams and a range of community health services . You will have your own case load of patients and deliver effective , coordinated care for vulnerable and frail adults, particularly those at risk of hospital emergency admission, emergency department attendances or out of hours care.

You will support multi-disciplinary team meetings , especially for patients in care homes.

We are looking for someone who is hardworking, organised with great interpersonal skills who will be committed to delivering the highest quality of care for our PCN. If you have what it takes and have the experience as follows, we would like to hear from you:

Experience in a patient focused environment.

Evidence of experience in wide range of administrative systems and software programme.

Experience of planning and organising complex meetings/agendas.

Evidence of working with IT systems.

Evidence of ability to support collation and analysis of data.

Evidence of supporting vulnerable Children and Adults in challenging situations.

Excellent verbal and written skills.

Ability to provide and receive complex information.

Experience of working in a GP practice Dispensary.

Excellent interpersonal skills.

Excellent team player.

Job Description:

• 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
• Support people to take up training and employment, and to access appropriate benefits where eligible
• Support people to understand their level of knowledge, skills, and confidence (their Activation level) when engaging with their health and wellbeing, including using the Patient Activation Measure
• Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level
• 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
• Support the coordination and delivery of MDTs within the PCN.