PCN - Care CoordinatorNHS

Job summary

An exciting opportunity has arisen for a Care Coordinator in the organisation, who must be available to work on a part time 22 hours per week practice based with flexibility when required to work across sites within PCNs. The role is advertised between 6-12 months and can be discussed during interview with the Clinical Director. This will be a fixed term contract. Practices across Waltham Forest have come to work collaboratively as Primary Care Networks (PCNs), pooling their resources and workforce to provide improved and integrated services for their patients. PCNs typically consist of 30,000-50,000 patients. Please note that we would be unable to take on any sponsorship visa's due to not having the budget or a licence.

Main duties of the job

Work within our network of GP Practices to provide a central co-ordination role for patient care planning. The role will be GP facing, with the core responsibility being excellent patient care.

You will be expected to take part in MDT meetings with GP and Nurse and present.

Co-ordinate care packages for patients as identified by the GP across health, social care and mental health as appropriate, providing a single-point of access for staff & service users, actively managing patients care plan delivery

Facilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support

Identify and work with a list of named patients with the aim of encouraging independence, enabling people to remain at home, reducing unnecessary admissions to hospitals and supporting early discharge from hospital, improving the quality of care.

Job description

Job responsibilities

1. Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames

2. Explain the management of a patients pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms

3. Work closely with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated and of the patients care plan, without requiring a further referral from the GP.

4. Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame.

5. Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations communications & patient notes and ensuring care packages are set up

6. Collect data on patients/carers for recognised outcome measure and document for service interpretation. Ensure all patient notes are updated to reflect any changes, including details on plans

7. Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and lead the meetings. Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance

8. Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.

9. Network and develop strong relationships with all levels of the NHSs key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector

10. Present in MDT meetings with GP and Nurse

Be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders

About us

WF GP FedNet is a not-for-profit Federation of 36 GP Practices in Waltham Forest. We are a private limited company who provides NHS Services based in Primary Care, pooling the skills and resources of local GPs to provide large scale services as part of the local NHS Strategy to bring more services into the Community to help people stay well and at home