PCN Care Coordinator inSouthall inSouthall PUBLISHED 29 OCT 2024

An exciting opportunity has presented for a motivated and enthusiastic Care Coordinator to work within a community mental health setting working alongside our primary care colleagues.

The Post holder will support the INT Leads, 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.

Our ideal candidate would be a committed team player as well as being able to work independently demonstrating initiative and passionate in promoting good quality care to maximise independence. Within this role you will gain training, support, and guidance to ensure you are working collaboratively with external agencies to give the best possible care for our service users.

Responsibilities include but are not limited to the following:

To work closely with the INT Leads, PCN Manager in supporting the Clinical Director, PCN practices and team in delivering the PCN Contract DES Specifications. The successful candidate will need to understand the importance of engaging with external agencies within our area in order for our service users to achieve high-quality care that we in Navigo always strive to deliver. This should involve using supervision and reflecting on practice to develop new and improved ways of working.

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

Assisting the INT leads & 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 Systmone along with booking and cancelling patient appointments.

Utilising population health intelligence to proactively identify and work with cohorts of patients across the PCN

Have a proactive approach, the ability to work on your own initiative and within a team environment.

This role will require the post holder to be based at Jubilee Gardens Medical centre and have the ability to visit PCN practices if and when required.

About us

Asa PCN Care Coordinator, you will work closely with member practices and the PCN in offering a personalised approach to caring for social and psychological needs of identified patients on your caseload, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.

You will also support other ARRS roles by contributing towards projects on an ad hoc basis to support health improvements to patients registered with member practices.

Your main duties will include:

Receiving and actioning referrals from a wide range of agencies, working with GP practices within the Primary Care Network (PCN), pharmacies, multi-disciplinary teams, hospital discharge teams and allied health professionals (list not exhaustive);

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 support the coordination and delivery of MDTs within the PCN

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care approach;

Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames;

Provide coordination and navigation for patients and their carers across the spectrum of services available;

Work alongside other PCN Additional Roles staff and outside agencies to provide wrap-around support to patients;

Make appropriate third-party referrals; andComplete and maintain accurate patient records.

This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to consider development within the practices. The post holder should be prepared to take on additional duties or relinquish existing duties to maintain the efficient running of the Network. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.

The roles involves travelling to PCN member practices as required for the service delivery.