PCN INT Care Coordinator / HCANHS
Job summary
To ensure the delivery of an effective and competent level of support to the PCN INT team by delivering a patient focussed service which promotes proactive care and effective working relationships.
The PCN INT Care Coordinator / HCA plays a central role in supporting frail and vulnerable patients to remain safe, well and independent at home. The role will be supporting both proactive and reactive patients, identified through risk stratification tool and will include basic observations and a supportive approach to person centre self-management. The post holder should work within their scope of practice, under agreed protocols, with escalation to registered clinicians as required.
The role will act as a bridge between GP Practices, MDT and other INT services.
Main duties of the job
The post holder will work across all PCN practices and as part of the wider Intergrated Neighbourhood team to ensure efficient and effective patient contacts and assit in the reduction of A&E admissions.
Job description
Promote and support a proactive approach in patient care, working with INT coordinators to identify patients from risk stratification tool and highlighted frequent attenders at A&E
Process and effectively signpost patients and their carers to the appropriate healthcare professional or health/social care, voluntary service depending on the presenting condition
Detect early signs of patient deterioration through basic observations and holistic approved assessment
Support the coordination, delivery and actions for MDTs within PCN
Increase patient confidence and understanding in their own health
Reduce crisis situations unplanned admissions and carer breakdowns
Support patients that are not managing their long term conditions, signposting to relevant services and highlighting concerns to GP practice
Liaise with PCN services, GP practices, community teams and voluntary services to support patients
Take part in hospital discharge reviews to assist in communicating and coordinating patient care
Action incoming emails and correspondence as necessary
Accurately detail information on patients records within the clinical system
Bridging the gap between GPs and realities patients face at home encompassing what really matters to them
Promote the image of the organisation and services by ensuring that all information and communication is up to date and suitably presented
Take responsibility for ensuring that internal and external communication systems are fit for purpose
Respond to telephone, email and written queries on behalf of the service area including call handling where appropriate
Demonstrate flexibility and adaptability to meet changing priorities within a dynamic operational environment
Be proactive and contribute ideas for improvement in the way the service is delivered
Support in providing telephone cover during annual leave, sickness or peak demand periods, including answering incoming calls, booking appointments, taking messages and signposting patients appropriately
Ensure that all complaints, compliments, concerns, comments and suggestions are escalated appropriately
Able to work on own initiative, prioritising work within defined policies and procedures to set timescales
Manage specific projects as requested by the PCN Operational manager and provide updates on progress
Develop use of community hubs for drop in BP monitoring sessions identifying hypertensive patients
About us
Folkestone, Hythe and Rural Primary Care Network is an innovative, friendly and forward thinking organisation.
We are proud and enthusiastic to be an inventive front runner in the development of Integrated Neighbourhood Team working, which is assisting in shaping the future of primary care, ensuring that patients receive positive and effective encounters enhancing their health and well being.
We are located in the historical South Kent Coast of the Garden of England (Kent). General Practice is changing at pace and we see this as a positive and opportunistic challenge.
Our PCN includes 7 practices with a combined list size of approx 52,000 patients.