Care Coordinator Primary Care Network

This is an exciting opportunity for a Primary Care Network Care Coordinator to join the Penge PCN.

This role is to support the smooth co-ordination of patient care across the Penge Primary Care Network for the benefit of patients. This role is advertised to work across Oakfield Surgery, Park Group Practice, Anerley Surgery, Robinhood Practice, Sundridge Medical Centre and Highland Medical Practice.

The Care Coordinator will be responsible for consulting with patients and determining their needs, developing care plans, coordinating patient-care services, educating them about their condition, empowering them to be independent whenever possible and working with the care team to evaluate interventions.

Key Responsibilities and Duties

• To work across a Primary Care Network
• To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence
• To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patient’s home if needed
• Improve uptake of care plans – i.e., BAME, learning disability
• Improve uptake of cancer screening programmes and childhood immunisations
• Support and coordinate covid-19 vaccine clinics

MDT Coordination

• Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the PCN practices. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting
• Identify patients to discuss at MDT meetings with a view to reducing unplanned admissions and exacerbation of conditions

Managing a Caseload

• Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence
• Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions
• Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacists, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews
• With the help of relevant clinical colleagues, develop a care plan to address patients’ personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including Emis Web.
• Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans
• Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans
• Check in on the patient regularly and evaluate and document their progress

Linking with Other Services

• Signpost team members, service users and carers to relevant services including the PCN Social Prescribing Link Worker Service
• Liaise with the Social Prescriber regarding patients that are identified as needing well-being support
• Liaise with PCN clinicians responsible for frailty regarding patients that are identified as needing ongoing support
• Liaise with acute trusts, hospices, community and social care providers as required

Record Keeping

• Keep accurate and up-to-date records of contact with patients, carers and professionals, including use of EmisWeb to record patient contact on the medical record
• Use accurate SNOMED codes to record patient contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomes
• Manage reporting required and associated within the DES specifications for required services
• Report case studies and outcomes to the PCN on a quarterly basis

General Responsibilities

• Work as part of the team to seek feedback, continually improve the service and contribute to business planning
• Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner
• Attend ongoing training and courses to keep abreast of new developments in health care
• Treat patients with empathy and respect and conduct oneself in a professional manner
• Attend and contribute to relevant meetings
• Duties may vary from time to time, without changing the general character of the post or the level of responsibility

Job Types: Full-time, Part-time, Fixed term contract
Contract length: 24 months
Part-time hours: 20-37.5 per week

Salary: From £27,000.00 per year

Benefits:

• Company pension

Schedule:

• Monday to Friday

Work Location: One location

Application deadline: 19/02/2023