Vacancy: PCN Care Coordinator

Job title: PCN Care Coordinator
Reports to: PCN Manager
Accountable to: PCN Clinical Director, Head of Additional PCN Staff
Work Location: Practice Based
Contract Type: Permanent
Hours: Fulltime 37.5 hours per week
Salary: £23,000 - £30,000 - depending on experience
Other: NEST Pension, 5 days of Study Leave offered

About us

The Confederation, Hillingdon CIC works with general practice and other healthcare providers in Hillingdon to deliver high quality clinical services to patients. Our aim is to improve care for patients by working collaboratively across primary care and our partners as part of the Integrated Care Partnership.

The Confederation team also work to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We are ‘of the NHS’ but independent, innovative and transformational.

General capacity across primary care is being expanded rapidly. The Confederation is determined to develop as an attractive place to work that provides rewarding roles and opportunities to grow in order to attract and retain great staff that in turn provides the highest quality care.

Job summary

An exciting opportunity has arisen within Primary Care to work as a Care Coordinator at The Confederation, Hillingdon CIC.

Care Coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to people and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

Care Coordinators could provide time, capacity and expertise to support people in preparing for, or following-up, clinical conversations. Enabling them to be more actively involved in managing their care and supporting them to make choices that are right for them. Care Coordinators help people improve their quality of life. The successful candidate will be caring, dedicated, reliable, person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills.

They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support. This role is intended to become an integral part of the PCN’s multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

Please note that the Care Coordinator works under delegation of a registered health professional.

To apply, please upload your Covering Letter and CV via this form. 

Primary Responsibilities:

The role will be to work within our network of GP Practices to provide a central coordination role for patient care planning as well as:

• Work with people, their families and carers, to improve their understanding of their condition.
• Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
• Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. 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.
• Provide coordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.
• Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
• Support the coordination and delivery of multidisciplinary teams with the PCN.
• Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations. 

To further develop the role, PCNs may wish to add the following additional responsibilities to the Job Descriptions:

• Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours.
• Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies.
• Conduct follow-ups on communications from out of hospital and in-patient services.
• Maintain records of referrals and interventions to enable monitoring and evaluation of the service.
• Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the person’s circumstances. 
•  

Collaborative Working Relationships:

• Foster and maintain strong links with all services across the PCN and neighbouring networks.
• Explores the potential for collaborative working and takes opportunities to initiate and sustain such relationships.
• Demonstrates use of appropriate communication to gain the co-operation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals, other NHS/private organisations e.g. ICBs).
• Can recognise personal limitations and refer to more appropriate colleague(s) when necessary.

Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to:

• Patients and their representatives.
• GP, nurses and other practice staff.
• Other healthcare professionals including community pharmacists, pharmacy technicians, social prescribers, first contact physiotherapists, physicians associate and paramedics.
• Community pharmacists and support staff
• Other members of the medicines management (MM) team including pharmacists, technicians and dieticians
• Locality/GP prescribing lead
• Community nurses and other allied health professionals
• Hospital staff with responsibilities for prescribing and medicines optimisation
• Community nurses and other allied health professionals

Health & safety/Risk Management

• The post-holder must comply at all times with all local Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System.
• The post-holder will comply with the Data Protection Act (1984) and the Access to Health Records Act (1990).

Equality and diversity

• The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc.

Patient Confidentiality

• The post holder must at all times respect patient confidentiality and, in particular, the confidentiality of electronically stored personal data in line with the requirements of the General Data Protection Regulation and in keeping with Hillingdon Primary Care Confederation Information Governance Policy and procedures.
• The post holder should not divulge patient information unless sanctioned by the line managerand required for the role.

Communication & Working Relationships:

• The post-holder will establish and maintain effective communication pathways at all times with project team members.

Special Working Conditions

• The post-holder is required to travel independently between sites (where applicable), and to attend meetings etc. hosted by other agencies.

Job Description Agreement

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 take into account development within The Confederation.

All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the service or function.

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.