PCN Care Coordinator

Job description

Job responsibilities

Key Duties Tasks and Responsibilities

Case Work Discussion

Overall responsibility for the regular multi-disciplinary team meetings and the smooth running of integrated care within the team setting. The key role of the Care Co-ordinator will be to schedule regular AHVT meetings, manage the meeting agenda items and identifying key themes for discussion, circulating information to the team in advance of the meeting.

Collate, analyse, and present data and information to the team.

Co-ordinate and manage the administrative functions of the AHVT meetings.

Note any key changes and team agreements and actions required and disseminate these to the team.

Manage the teams database to track case management, service user journeys and outcomes, and undertake analysis of caseload information for audit, service evaluation, and performance management purposes, to be reported back to the MDT and Team Up Clinical and Operational Leads.

Patient Identification

Receive and collate information from hospital admissions and discharges, plus out of hours calls, ambulance conveyances, and social care, and present this to the AHVT.

Identify people with complex needs and new service users and present this information to the AHVT.

Signpost team members, service users, families, and carers to relevant services, referring as appropriate.

Contribute to assessment to identify a specific need, to maintain independence in the place they call home (own home, residential or care home). Attend visits as appropriate to act as chaperone or to facilitate non-clinical referrals.

Maintenance of IT based information systems and responsibility for key performance data

To ensure the IT requirements for recording activity are adhered to in collaboration with other team members.

To analyse and provide agreed performance/activity data on behalf of the AHVT for monthly reporting to the Integrated Care Board, and to support ongoing evaluation and success of the service.

Communication and Relationships

Work closely with health and social care system partners to ensure referrals into the service are received and managed, and to co-ordinate personalised care for the patients on the caseload.

Develop excellent working relationships with internal and external stakeholders and communicate effectively with service users, families, carers, residential and care homes, AHVT members and other organisational representatives to ensure there is smooth access into the service, and to ensure patients receive the input they need from other services as required.

Fulfil an intermediary role between administrative staff, clinicians, social workers, allied health professionals, community teams and mental health teams.

Maintain relevant systems for colleagues involved in care, to be able to access.

Communicate to the team and relevant organisations of any good news case management stories.

Refer complex cases to the AHVT via multi-disciplinary team meetings.

Build networks within the scope of the role to raise awareness and identify groups and services available within the community.

Raise any potential safeguarding concerns with the relevant clinicians within the team

Liaise with AHVT members to ensure any outstanding actions required by team to follow-up/facilitate tests or treatment/onward refer patients to other services.

Produce accurate, contemporaneous, and complete records of patient contact, consistent with legislation, policies, and procedures.

Understand own role and scope, work within this scope of practice and identify how this may develop over time.

Supporting Care Delivery

Be a key point of contact for service users, families, carers, residential and care homes, ensure there is a key point of contact within the team for all service users from a clinical perspective, and act as an advocate for patients, families, and carers to support the assessment and identification of specific needs to maintain independence in the community.

Prepare proactive care plans for appropriate patients.

Work with the clinical team to provide proactive care for health promotion and/or long-term condition monitoring and management.

Follow through actions identified by the AHVT including arranging tests, referrals, signposting etc.

Follow through with service users and others involved to ensure all services/care arrangements are in place.

Provide welcome home calls after acute or community hospital stays for individuals who are frequent flyers, have complex needs or are at risk of readmission.

Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence.

Discuss, highlight, and work with the team to create opportunities to improve patient care.

Other Responsibilities

Manage and prioritise workload daily and deal with the competing demands of the team.

Plan and respond to workload according to operational priorities.

Participate in the induction of new staff to the team as required.

Take part in regular performance appraisal.

Take responsibility for self-development on a continuous basis and undertake any training required to maintain competency including mandatory training.

Participate in audits/service evaluation and learning events necessary to the team.

Use own initiative to follow up activities, facilitate smooth service delivery for service users and to act as facilitator to ensure actions required by the team are undertaken as appropriate.

At times, lead or contribute to the planning and delivery of improvement projects.

Participate in the maintenance of quality governance systems and processes across the organisation and its activities.

Disseminate learning and information gained to other team members to share good practice.

Assess own learning needs and undertake learning as appropriate.

The list of duties above is not exhaustive and is intended to outline the main activities of the post holder.

Person Specification

Qualifications

• ECDL or equivalent Diploma/HNC level (or relevant experience)
• NVQ Level 2 Business Administration (or relevant experience)
• Demonstrable commitment to professional and personal continuous development.

• Training in motivational coaching and interviewing or equivalent.
• Knowledge of primary care IT Systems Qualified to NVQ level 2 in Health and Social Care.

Experience

• Experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field (including unpaid work)
• Experience of data collection and providing monitoring information to assess the impact of services.
• Experience of partnership/collaborative working and of building relationships across a variety of organisations.
• Experience of working with or in general practice.
• Working in a multi-disciplinary setting where influence and negotiation is required.
• Knowledge/familiarity with medical terminology.

• Experience in use of databases.
• Vulnerable adults awareness.
• Experience of care of the elderly or frail
• Experience of using SystmOne

Skills and Knowledge

• Knowledge of the personalised care approach.
• Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails, and the internet to create simple plans and reports.
• Creative problem solver and willing to search for hard-to-find information.
• Meets DBS reference standards and has a clear criminal record in line with the law on spend and convictions.
• Access to own transport and ability to travel across the locality on a regular basis.
• Continued commitment to improve skills and ability in new areas of work.

• Knowledge of general practice clinical systems, such as, EMIS and SystmOne. Ability to read large amounts of information and extract the salient points.
• Data analysis and reporting.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Derbyshire Dales Primary Care Network

Address

Whitworth Hospital

330 Bakewell Road

Matlock

Derbyshire

DE4 2JD

https://ddpcn.co.uk/