PCN Care Coordinator

We are looking for 1 WTE and 1 Part time PCN Care Coordinators with excellent communication and administrative skills to work with the GPs and other clinicians within the Waterloo Health Centre. You will be working with GPs and other clinicians, to assist patients in the management of their care. One of successful care coordinators will concentrate on providing Administration support across practices as well as Care Coordination.

You will be none judgmental, empathetic as the first point of contact for patients, clinicians and community carers. Identifying personalised care plans, engaging them in training and employment to improve their wellbeing., North Lambeth Primary Care Network are excited to advertise a new role in our network As a Care coordinator you will play a crucial role in supporting patients in preparing for or in following-up clinical conversations they have with primary care professionals.

You will work closely with the GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. You will focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification., 1.

Undertake work in line with PCN directed priorities. 2. Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids 3. Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance 4. Raise awareness of health promotion and NHS health checks in practices 5.

Work with Member Practices to facilitate the . 6. Evaluate treatment programmes that promote health and well-being 7. Co-ordinate clinics, liaising with the schedulers and contacting the identified patients with appointments. 8. Manage patient initiated calls for help/signposting etc, booking into named GP urgent care slots/tel slots if necessary. 9. Document and monitor aspects of patient co-ordination and service delivery, supporting data collection and audit using the patient administration system 10.

Demonstrate the ability to recognise and respond appropriately when faced with a sudden deterioration or emergency situation, alerting the team or enabling a rapid response. 11. Dependant on work plans, there may be a requirement to work across different tumour groups and teams. 12. Organise and prioritise own workload the postholder should be comfortable working independently and as a committed member of the multi-disciplinary team.

13. Support national screening programmes 14. Support immunisation programmes 15. Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact 16. Direct liaison with multi agencies to coordinate care for patients 17. Refer to PCN social prescribing link workers were a patient is identified as potentially benefitting from this service 18. To support patient/carer contact roles, and collate patient and carer feedback on their experiences 19.

Support Quality and Outcome Frameworks and other DES/LES specifications 20. Maintain and develop engagement with all practice staff and encourage best practice 21. Act as the first port of call for patients, in their caseload in relation to their care. 22. Bring together all of a persons identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP), in line with PCSP best practice 23.

Help people to manage their needs, answering their queries and supporting them to make appointments 24. Support people to take up training, employment and access appropriate benefits where eligible 25. Raise awareness of shared decision-making and decision support tools, and assist people to be more prepared to have a shared decision-making