Job Description

The Complex Care Coordinator will be required to support and coordinate health services across our PCN, working closely with the Complex Care Team.

They will play a key role in supporting patients with long term conditions and mental health issues across the Primary Care Network. The post holder will work with patients, families, carers, and multidisciplinary teams to ensure care is joined up, personalised, and responsive. The role focuses on proactive case management, coordination of services, and navigation of the health and social care system to improve patient outcomes and reduce health inequalities.

Working in partnership with primary and secondary care doctors, nurses, mental health practitioners, healthcare assistants, social prescribing link workers, occupational therapists, physiotherapists, therapists and clinical pharmacists.

The role will be an integral part of the Complex Care Team, working in the community across the PCN.

The following are the core responsibilities of the Care Coordinator within our team. There may be on occasion a requirement to carry out other tasks; this will be dependent on factors such as workload and staffing levels:

Working closely with the patient and their clinician or other healthcare professionals, the Care Coordinator will establish and provide:

Patient Care and Case Management

Act as a central point of contact for patients with complex health and care needs, including long term conditions and mental health issues.

Undertake holistic assessments, identifying medical, psychological, and social support requirements.

Develop and maintain personalised care and support plans in collaboration with patients, families, and clinical teams.

Monitor patients' progress, reviewing care plans regularly, and adapting support as needs change.

Support patients to self-manage their conditions where possible, promoting independence and wellbeing.

Care Coordination

Liaise with GPs, practice nurses, mental health services, community teams, social care, and voluntary sector organisations to ensure integrated care delivery.

Proactively identify patients at high risk of hospital admission or deterioration and coordinate appropriate interventions.

Facilitate smooth transitions of care, such as hospital discharge planning and onward referrals.

Actively signpost patients to the correct healthcare professional.

Ensure that patients have timely access to mental health support, signposting and escalating as necessary.

Assist patients to access self-managementeducation courses, peer support or interventions that support them in their health and well-being.

Where appropriate, to assist patients to access personal health budgets.

Where appropriate, to support people to access appropriate benefits where eligible as well as taking up employment and training.

Provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working closely with social prescribing link workers, occupation therapists and other primary care professionals.

All staff have a duty to conform to the following:

Share best practice across the PCN.

Be responsible for the day-to-day planning of personal workloads.

Follow departmental policies, procedures and guidelines.

Develop yourself and the role through participation in training and service redesign activities.

Contribute to a patient safety culture through reporting and investigation of incidents and undertaking proactive measures to improve patient safety

The ideal candidate should have the following:

-GCSE A*- C or equivalent

- Experience in care coordination or clinical administration

- Excellent communication and organisational skills

- An excellent understanding of Data Protection and confidentiality

- Attention to detail

- Independent and team working skills

Applicants should also have:

A full UK driving License or suitable access to transport to be able to travel to sites within the PCN area

DBS check (will be conducted by Marina PCN upon job offer)

Flexibility to work outside core office hours.

Flexible and cooperative.

Polite and confident.

Job Types: Full-time, Permanent

Pay: 14.06-15.43 per hour

Experience:

Care Coordinator or Clinical Administration: 1 year (required)
Work Location: In person