Job Description

Please note that the role of a Care Coordinator is NOT a clinical role. The post holder will be responsible for the provision of wide-ranging and efficient administrative support the Hyndburn Rural Primary Care Network (PCN). Typically this support may include the arrangement of meetings, dealing with correspondence, document management, preparing short reports, creating spreadsheets, responding to and the forwarding of e-mails and other administrative tasks such as the minute taking of PCN meetings. The post holder may from time to time be required to work from different practices within the area so will require a degree of flexibility and a range of duties that may vary as the service develops.



The Care Coordinator will be part of the Primary Care Network (PCN) Administration Team responsible for supporting the care of patients. registered with practices within the Hyndburn Rural PCN. This may involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population. The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions.



An ethos of promotion of independence and partnership-working is integral to this post. Key aspects of this role will include supporting the following PCN activities: - Direct Enhanced Service (DES) - Enhanced Health in Care Homes Taking a lead in the organisation of the formal joint PCN meetings (PCN Clinical and PCN Community) Staff Introductory Flyers Regular cascading of information to GP Practices and PCN Stakeholders Population Health Management Review of the PCN generic e-mail address In addition they will work closely with the MDTs through supporting the identification of people in need of review, or collation of information on people requiring an MDT review in addition to providing coordination, secretarial and administrative support to the MDTs within a single or multiple PCNs. Communication and Key Working Relationships Demonstrates ability to work as a member of a team. Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary.



Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs. Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff, other healthcare professionals and commissioning organisations. Acting as a point of contact when required for people who wish to contact the PCN. Communicate effectively with service users and their families / carers, and other staff both internal and external and members of the public.



Responds positively, in a courteous and professional manner when dealing with routine and non-routine enquiries which may be complex and involve problems in communication / understanding. This includes general non-clinical advice and information to patients and carers. Acts with discretion at all times to take and record accurate messages. Communicates complex and highly sensitive information which may relate to staff, patients and relatives or commercial undertakings, within and outside the organisation, with the ability to persuade, negotiate and influence others.



To help maintain excellent communication, liaison and working arrangement with Trust Directorates, Trusts, NHS England, East Lancashire Clinical Commissioning Group, Social Services, Voluntary Sector Organisations, Care Homes and other agencies. Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other key PCN stakeholders. Meet regularly with the clinical & management leads of the Direct Enhanced Services. Manage and prioritise workload on a daily basis and deal with the competing demands of PCN Admin work.

Key Working Relationships Internal:

Clinical Lead & Management Lead for the Direct Enhanced Services (DES - EHCH) GPs and General practice teams within the PCN PCN Clinical Director PCN Admin Team Lead DES: Clinical Pharmacists, Pharmacy Technicians, Social Prescribing Link Workers, Dieticians, Occupational Therapists, Health & Wellbeing Coaches, District Nurses, Adult Social Care, Community Paramedics and other ELHT and LSCFT Medical Teams as appropriate, plus other key stakeholders. PCN Hyndburn Rural Care Home & Housebound ANP Team Key Working Relationships External: GPs and GP Practice Managers from neighbouring PCNs Service providers Social care Voluntary services Patients / service users Carers / relatives Care Home staff Planning and Organisation Manages and prioritises all incoming and outgoing correspondence, initiating responses where appropriate. Manages the diaries of key members of the team when required including maintaining and co-ordinating appointments, organising meetings (including video conferences via Microsoft Teams) and using initiative to make necessary revisions, liaising with all relevant parties in an efficient and effective way. Prepares agendas, collating and circulating papers for meetings, ensuring that all papers are submitted in time and that they comply with the required house style standards.



Selects, retrieves and collates papers and information in a timely manner, for meetings and in response to enquiries. Attends meetings, taking and transcribing formal minutes and action notes. Manages the organisation of events or meetings which involves sending invites, arranging speakers / lecturers and booking venues. Organises and prioritises workload and works flexibly in response to competing demands.



Manages reporting required and associated within the DES (EHCH) specifications for required services. Provides an efficient and comprehensive secretarial and clerical support to the DES meetings and members of the team on a day to day basis using knowledge and experience of procedures and practices when making task related decisions and resolving non-routine issues. Manages all DES activity for GPs and all those involved in these work streams, by post, telephone or email and ensures that action required is undertaken within the agreed timescale. Liaises with all clinical and non clinical members in connection with the DES (EHCH) work streams.



Support the Hyndburn Rural Care Home & Housebound ANP Service with running patient searches when appropriate. Analytics Considers a variety of issues and proposes solutions when dealing with complex enquires by taking appropriate action as necessary or liaising with others/redirecting queries as appropriate. Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. Support the process of allowing patients to utilise decision aids in preparation for a shared decision making conversation.



Evaluates team diaries and makes decisions to maintain and coordinate appointments. Undertakes any project work as required, including obtaining information from the internet, analysing, collating and reporting of data in order to produce reports, spreadsheets and presentations utilising relevant IT systems. Ensures the Information Technology (IT) requirements for recording activity are adhered to in collaboration with other team members. Ensures accurate update and maintenance of GP systems within Multi-Disciplinary Team working (MDT).



Provides agreed performance / activity data within the DES (EHCH) Work streams and PCN and to wider organisations as requested. Responsibility for Patient/Client Care, Treatment & Therapy Support the process of holistically bringing together all of a persons identified care and support needs and explore options to meet these within single personalised care and support plan (PCSP), in line with PCSP best practice based on what matters to the person. Support the process of helping patients to manage their needs through answering queries, making and managing appointments and ensuring that patients have good quality written or verbal information to help them make choices about their care. Support the process that allows patients to take up training and employment and to access appropriate benefits where eligible.



Assist the process for patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing increase their activation level. Supports the process of patients being able to access personal health budgets where appropriate. Provide co-ordination and navigation for patients and their carers across health and care services, working closely with Social Prescribing Link Workers, Health & Wellbeing Partnership Coaches and other primary care professionals. Effectively uses all methods of communication and is aware of and manages barriers to communication.



Provides information to patients, their carers and/or relatives on behalf of the team. Is the point of liaison for service users and interfaces with all health and social care professionals, including keeping everyone informed and updated. Receives and collates information in connection with the DES (EHCH) work streams. Is able to use risk stratification tools provided and supports presentation information in review meetings.



Follows through actions identified in the DES (EHCH) work streams including arranging tests, referrals, signposting, etc. For more information please see the Job description attached.