We are seeking a dedicated and detail-oriented PCN Care Co-Ordinator to join our healthcare team. The ideal candidate will play a vital role in coordinating patient care within the Primary Care Network (PCN), ensuring seamless communication and efficient management of patient services. This position offers an opportunity to contribute to improved patient outcomes through effective care coordination and collaboration with multidisciplinary teams. The PCN Care Co-Ordinator will be responsible for managing patient appointments, supporting clinical staff, and facilitating access to healthcare resources. Strong organisational skills, excellent communication abilities, and a compassionate approach are essential for success in this role.
JOB PURPOSE
The Care Coordinator role is seen as a critical and evolving post to support the PCN multi-disciplinary team to deliver effective, co-ordinated and personalised care for patients. This role will specifically focus on patients living in care homes, supported living environments and elderly and frail patients living independently in their own homes
The post holder will support people at home to live in the least restrictive way and those living in care homes and supported living environments to remain empowered and ensure that their voices are heard
To act as the first point of contact for GPs, Adult Social Care, Care Homes, other Community Services and VCSE organisations regarding matters relating to a person's care and support needs
The post holder will work in a supportive capacity with both the PCN Wellbeing team, assisting with administrative tasks as required. Including: personalised care and support plans (PCSPs), referrals, minute-taking and signposting
The role will also involve working in a supportive capacity with the teams in each GP Practice and linking in with a range of community health and social care services, care homes and the VSCE
KEY WORKING RELATIONSHIPS
Patients, Patient's families, Carers and Support Workers.
PCN Strategic Manager, GPs, Practice Nurses, Pharmacists, Pharmacy Technicians, Mental Health Practitioners, Social Prescribing Link Workers, Paramedics, First Contact Physiotherapists, Practice Administration and Dispensary teams.
Care Home Managers and their Teams.
Adult Social Care, Cornwall Foundation Trust (CFT), VSCE organisations.
Community Nurses and other Allied Health Professionals
RESPONSIBILITIES UNDERPINNING THE ROLE
The Care Coordinator has the following key responsibilities, in delivering health services:
Work with GPs and other Primary Care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the PCN and / or practices
Help patients to manage their needs by answering queries and ensuring that patients have good verbal or written information to help them make informed choices about their care
Provide co-ordination and navigation for patients and their carers across health and social care services, working closely with Primary Care Health professionals, Adult Social Care and Social Prescribing Link Workers
Work collaboratively with patients to write PCSPs and if applicable and the person has consented, ensure this information is shared with all relevant parties - families, carers and other health care professionals, holistically bring together all the patient's identified care and support needs
Provide support for carers and link in with appropriate local services
Raise awareness within the PCN of shared decision making and decision support tools. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations
To follow appropriate safeguarding procedures
To attend MDTs and minute meetings where appropriate
ADMINISTRATIVE RESPONSIBILITIES
To use BRAVE AI in line with PCN requirements to proactively identify patients and as a referral tool into MDT discussions, most notably MHP MDTs, though this may expand in line with the needs of the business
To work as a key member of the MDT to help support the development of effective MDT meetings., including minute taking, where applicable
To update care plan templates within EMIS ensuring accuracy with read codes used.
Act as a non-clinical contact for the care home to assist with case management of patients at risk of admission; working with the ANP / GP to identify sources of support in liaison with case managers.
To work with the wider MDT to identify appropriate case managers for high-risk patients to ensure that patients are reviewed and anticipatory care plans are developed
Ensure that all patients' Anticipatory Care Plans, diagnostics results, and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available
To liaise with acute hospitals and coordinate the sharing of key information between the acute hospital teams and the MDT team
Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute / community hospital setting
To support the PCN MHPs and Social Prescriber with all administrative tasks including but not limited to support the planning and development of community wellbeing days, support with signposting, complete PCSPs on their behalf
WORKFORCE RESPONSIBILITY
The post holder must remain up to date with mandatory training as required
PERSONAL QUALITIES
The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative, and demonstrate consistently high standards of professionalism.
The post holder must always be aware of the need for confidentiality and integrity.
The post holder will need a basic knowledge of Health and Social Care terminology, eligibility criteria and current team structures and pathways.
ENVIRONMENTAL FACTORS
The post holder will be required to drive and must have access to a car and hold a full clean driving licence
The post holder may be required to undertake duties at any location in the community to meets service needs
Concentration required for data analysis, tracking patients and meetings, frequent interruptions requiring attention and re-prioritisation of work
Job Types: Full-time, Part-time, Permanent