Care Coordinator in Elland inElland PUBLISHED THU 6 MAR 2025 Jump to job information section

Calder & Ryburn Primary Care Network (PCN) consists of four GP practices and have a combined patient list of over 43000 patients. We have grown as a collaborative PCN over the past five years and now have over 30 members of staff working across the PCN.

Calder & Ryburn PCN are looking for a self-motivated individual to join our growing personalised care team to cover 12 months of maternity leave. The team currently consists of care coordinators and social prescribing link workers who all work in GP practices across the PCN.

Undertake work in line with PCN directed priorities.

Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids.

Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance.

Raise awareness of health promotion and NHS health checks in practices.

Support national screening programmes.

Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact.

Direct liaison with multi agencies to coordinate care for patients.

Refer to PCN social prescribing link workers where a patient is identified as potentially benefitting from this service.

To support patient/carer contact roles and collate patient and carer feedback on their experiences

Support Quality and Outcome Frameworks and other DES/LES specifications.

Maintain and develop engagement with all practice staff and encourage the best practice.

Act as the first port of call for patients, in their caseload in relation to their care.

Bring together all of a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan (PCSP), in line with PCSP best practice.

Help people to manage their needs, answering their queries and support them to make appointments.

Support people to take up training, employment, and access appropriate benefits where eligible.

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Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation.

Ensure that people have good quality information to help them make choices about their care.

Support people to understand their level of knowledge, skills and confidence 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.

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, alongside working closely with social prescribing link workers and other primary care roles.

Support the coordination and delivery of care home ~MDTs within PCNs ensuring the enhances health in care homes model is delivered.

Supporting residents in care homes/LD homes ensuring personalised care is delivered through collaborative working between health, social care, voluntary, community and social enterprise sector and care home partners.

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect staff will respect their privacy and act appropriately.

In the performance of the duties outlined in this job description the post-holder may have access to confidential information relating to patients, their carers, practice, or staff information. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, or member practices may only be divulged to authorised person in accordance with PGPA policies and procedures relating to confidentiality and the protection of personal and sensitive data, or under the guidance of your manager.

Where required competently carry out elements of the health check (A full check involves measurement of body mass index and waist circumference, pulse rate, blood pressure, height and weight, QRISK measurement, blood glucose, blood lipid, smoking and alcohol) and where required refer for further clinical advice.

To maintain up to date knowledge of legislation, national and local policies and issues in relation to the specific client group, mental health and community care delivery.

To comply with the Professional Codes of Conduct and to be aware of changes in these. To maintain up to date knowledge of all relevant legislation and local policies and procedures implementing this.

To ensure that all duties are carried out to the highest standard and in accordance with currently quality initiatives within the work area.

To comply with all relevant organisations policies, procedures, and guidelines, including those relating to Equal Opportunities, Health and Safety and Confidentiality of Information and to be aware of any changes in these.

To comply at all times with the PGPAs Information Governance related policies. Staff are required to respect the confidentiality of information about staff, patients and PGPA business and in particular the confidentiality and security of personal identifiable information in line with the Data Protection Act. All staff is responsible for ensuring that any data created by them is timely, comprehensive, accurate, and fit for the purposes for which it is intended.