Care Coordinator - Havering Liberty PCN inRomford inRomford PUBLISHED MON 28 OCT 2024

The Post holder will support the PCN Manager, Clinical Director and wider PCN team including the PCNs member practices, and multidisciplinary team (MDT) within the PCN with project work as well as general core support to the PCN with a wide range of administration and associated tasks across the network. They will assist coordination of all key activity including access to services, advice, information, and ensuring health and care planning is timely, efficient, and patient-centred.

Responsibilities include but are not limited to the following:

To work closely with the PCN Manager in supporting the Clinical Director, PCN practices and team in delivering the PCN Contract DES Specifications.

Undertaking a wide range of administrative duties and providing administrative support to the Primary Care Network and team, including arranging monthly PCN and MDT meetings, minute taking and recording.

Assisting the PCN Manager with their relationships and engagement with the PCN practices and other stakeholders across the locality to ensure a collaborative approach to service development and delivery.

Build and maintain PCN clinics on EMIS along with booking and cancelling patient appointments.

Utilising population health intelligence to proactively identify and work with cohorts of patients across the PCN e.g. flu clinics, COVID booster.

Supporting all member practices with data quality issues relating to PCN contracts, enhanced services and IIF/QOF.

Management of the PCN Website and support PCN digital work streams.

Working with the PCN Manager and DTL to develop and operationalise new PCN led projects and technologies as they immerge.

To support the PCN Manager and Practice Managers with Additional Roles Team alignment to the PCN practices e.g. HR issues, induction programmes, recording of mandatory and role specific training.

This role will require the post holder to be based at St Georges Wellness Hub, have the ability to visit PCN practices if and when required.

About us

Key Duties & Responsibilities:

The Care Coordinator responsibilities include but are not limited to the following:

To work with the GPs and other primary care professionals within the Primary Care Network (PCN) to identify and manage a caseload of patients who would benefit from support through care coordination

To work closely and in partnership with the Social Prescribing Link Worker and Health and Well-being Coaches to assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.

Work with patients, their families and carers to improve their understanding of the patients condition and support them to develop and review personalized care and support plans to manage their needs and to achieve better healthcare outcomes.

Identity unpaid carers and help them access services to support them and place them on the carers register

To support patients to utilise decision aids, help create single personalised care and support plans, in line with best practice.

To support the PCN in the delivery of the DES specifications, such as tackling health inequalities through targeted work with specific groups identified through population health management

To 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

To provide coordination and navigation with the aid of digital tools for people and their carers across health and care services

To support the coordination and delivery of MDTs within the PCN

Collaborative working relationships

Works within the primary care team, contributing to leadership of service evaluation and research to promote quality improvement activity.

Collaborates with multi-disciplinary PCN team

Uses healthcare technologies to optimise service delivery, patients access, and continuity of care

Management

Demonstrates understanding of the implications of national priorities for the team and/or service.

Uses resources effectively to manage patient treatment in line with local guidance and makes recommendations for change where improvements can be made.

Follows professional and organisational policies

Education, learning and development

It is the responsibility of the employee to comply with all organisational and statutory requirements (eg. health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance).

Engages in annual appraisal, developing objectives to inform a Personal Development Plan, which may include 360-degree appraisal and use of patient feedback.

Participate in teaching and training of medical, nursing, and all other practice staff.

Supports the practice staff and responds to requests for advice and assistance.

Complete all mandatory and statutory training required by the role.

Takes responsibility for personal development, learning and performance and maintain education through attendance on any courses and/or study days necessary to ensure that professional development requirements are met.

Undertakes additional training where necessary to provide enhanced services and participate in training programmes implemented by the PCN/practices as part of this employment.

Understands and demonstrates the characteristics of a role model to members in the team and/or service.

Demonstrates an understanding of current educational policies relevant to working areas of practice and keeps up to date with relevant clinical practice.

Quality

Under supervision and support of GPs in the practice, the post-holder will strive to maintain quality within the practices, and will:

Participate in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and Quality Improvement

Alerts other team members to concerns about risk, quality, and safety

Participates in investigation of incidents and events as required

Identifies, applies, and disseminates research findings relating to own practice

Collects data for audit purposes and uses clinical audit to monitor quality in the service

Contributes to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance

Works effectively with individuals in other agencies to meet patients needs

Effectively manages own time, workload, and resources

Meets timescales/deadlines for audits and written returns to ensure that the Practice meets quality standards and receives the designated funding.

Confidentiality

In the performance of the duties outlined in this Job Description, the post-holder will have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the Company as a business organisation. All information is to be regarded as strictly confidential.

Maintains confidentiality of any information concerning patients in accordance with current policy on information governance.

Demonstrates respect for privacy and confidentiality in all interactions with patients and the public.

Data Protection

This post has a requirement for confidentiality. If you are required to obtain, process and/or use information held electronically you should do 'it in a fair and lawful way. You should hold data only for the specific registered purpose and not use or disclose it in any way incompatible with such a purpose. Data must only be disclosed to authorised persons or organisations as instructed. Breaches of confidence in relation to data will result in disciplinary action which may involve dismissal.

You must not at any time use the personal data held by the organisation for any purpose other than practice business and this must not be disclosed to a third party. If you are in any doubt regarding your responsibilities under the Data Protection Act 2you must contact your line manager or appropriate senior lead at the time.

Safeguarding adults and children

The postholder has a duty to safeguard and promote the welfare of vulnerable adults and children.

When adults or children and/or their carers use primary care services, it is essential that all adult and child protection concerns are both recognised and acted on appropriately.

The postholder has a responsibility to ensure they are familiar with and follow local policies in relation to safeguarding vulnerable adults and that they follow the local child protection procedures and any supplementary guidance.

The postholder has a responsibility to support appropriate investigations either internally or externally.

To ensure the postholder is equipped to carry out their duties effectively, they must also attend vulnerable adult and child protection training and updates at the competency level appropriate to the work they do and in accordance with the local vulnerable adult and child protection training guidance.

Health & Safety

Assists in promoting and maintaining their own and others health, safety and security as defined in the PCN Health & Safety Policy, to include:

Using personal security systems within the workplace according to practice guidelines

Adhere to the guidance within the Lone Workers policy, when making home visits

Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks

Making effective use of training to update knowledge and skills

Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards

Reporting potential risks identified

Complies with policies for infection control and hand hygiene to reduce the spread of healthcare-associated infections. For clinical staff with direct patient contact, this will include compliance with clinical procedures and protocols, including uniform and dress code, the use of personal protective equipment policy, safe procedures for using aseptic techniques, and safe disposal of sharps

All staff are required to attend mandatory training in Infection Control and be compliant with all measures known to be effective in reducing healthcare-associated infections

Equality and Diversity

Supports the equality, diversity, and rights of patients, carers and colleagues that includes:

Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation

Respects the privacy, dignity, needs and beliefs of patients, carers and colleagues

Flexibility

This job description is not intended to be exhaustive. The post-holder will be expected to adopt a flexible attitude towards the duties outlined which may be subject to amendment at any time in consultation with the post-holder and in line with the needs of the organisation

The post holder may be required to fulfil other duties, as agreed with the practice manager /line manager to meet the needs of the organisation. This will involve travel to other sites within the organisation

Security

It is the responsibility of all employees to work within the security policies and procedures of the practices they work at to protect the patients, staff, and visitors. This duty applies to the specific work area of the individual and the practice in general. You are expected to wear ID and to sign in and out of practices you are working at