Job Description
Job Title: Primary Care Network (PCN) Care Coordinator
Responsible to: Clinical Director and PCN Operational Lead
Place of Work: The post holder will be required to work at various GP Practices across South Islington PCN and within different team settings, in line with the needs of the service.
Hours: 37.5 hours per week (Monday - Friday)
Salary: £28,840 per annum
Duration: 12-Month Fixed-Term with Possibility of Extension
About Islington GP Federation
Islington GP Federation (IGPF) is a growing organisation representing 31 practices; we have established ourselves as a leader in new ways of working, including running Islington’s extended access primary care services (I:HUB) as well as supporting the Islington Primary Care Networks (PCNs). Our current range of services include the Extended Access Service, I:HUB, Community Ear, Nose and Throat (ENT), Integrated Community Gynaecology, practice-based pharmacists and a range of practice support mechanisms.
IGPF works very closely with a range of partners including the regional commissioning group, NHS England, Healthy London Partnership, Public Health, local hospitals such as UCLH and the Whittington Health and the London Borough of Islington.
IGPF is the host organisation for the Primary Care Network (PCN) workforce and the Islington Training Hub, and has been working for over two years to create training and development programmes that meet the needs of staff working in primary and community care settings. IGPF runs two Islington GP practices on caretaking contracts; a third practice will be taken on within this financial quarter.
Purpose of The Role
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 them 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, review patients’ needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.
Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.
KEY RESPONSIBILITIES
- Work with people, their families and carers to improve their understanding of their conditions and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their ‘Activation’ level.
- Support people to take up training and employment, and to access appropriate benefits where eligible.
- Provide coordination and navigation for people and their carers across health and care services, working closely with paramedics, social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined up service and the most appropriate support.
- 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.
- Identify unpaid carers and help them access services to support them;
- 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
KEY TASKS
1. Enable access to personalised care and support
- Take referrals for individuals or proactively identify people who could benefit from support through care coordination;
- Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs;
- Support people to develop, implement and review personalised care and support plans
2. Coordinate and integrate care
- Help people transition seamlessly between services and support them to navigate through the health and care system;
- Refer onwards to social prescribing link workers and health and wellbeing coaches where required;
- Actively participate in multidisciplinary team meetings in the PCN as and when appropriate;
- Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns
3. data and information capture
- Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation;
- Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing;
- Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives
4. Professional development
- Work with a named clinical point of contact for advice and support.
- Undertake continual personal and professional development, taking an active part in reviewing an developing the role and responsibilities, and provide evidence of learning activity as required;
- Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
- Engage with and attend relevant local and regional peer support groups and training
5. Miscellaneous
- Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner;
- Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning;
- Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities;
- Work in accordance with the practices’ and PCN’s policies and procedures
Person specification
Experience - Essential
- Social or Health Care/ qualifications or equivalent experience
- Application of outcomes-based approaches to care and support
- Working with at-risk individuals in a social care type role
Skills - Essential
- Carrying out Care Planning and Coordination processes.
- Using IT based case management systems
- Effective and confident written and verbal communication to wide range of patient and practitioner audiences
- Identifying and resolving patient issues sensitively within service and professional boundaries
- Able to build supportive and trusted working relationships
- Able to prioritise and manage own workload
- Working as part of a multidisciplinary team
Skills - Desirable
- Working with people on a one to one basis in a coaching role
- Personalised working using motivational interviewing techniques
Knowledge - Essential
- Relevant voluntary and community sector services knowledge
- Patient confidentiality, privacy and dignity best practice requirements
Knowledge - Desirable
- Core health and social care processes and integrated working approaches
Aptitude - Essential
- Commitment to delivering a high quality and safe service
- Able to communicate with clients and professionals at all levels
- Able to manage own work load and prioritise competing pressures
- Willingness to undergo further training or development
Aptitude - Desirable
- Able to assess risk when lone working
Job Types: Full-time, Fixed term contract
Contract length: 12 months
Salary: £28,840.00 per year
Benefits:
Schedule:
Application question(s):
- Do you have experience working in a GP Practice?
Experience:
- General Practice: 1 year (required)
Work Location: One location
Application deadline: 12/02/2023
Reference ID: Careco