LS25-26 PCN Care Co-ordinatorNHS

Job summary

HOURS: 30 hours per week

ACCOUNTABLE TO: Operations Team Leader

HOSTED BY: South East Leeds GP Group

SALARY: £25000 Pro Rata Per Annum

PLACE OF WORK: GP Practices across our PCN

THE OPPORTUNITY

This role will be hosted by South East Leeds GP Group and will be based in the LS25 LS26 Primary Care Network (PCN).

LS25/26 PCN has a patient population of circa 75,000 across 7 practices:

Garforth Medical Centre

Gibson Lane Practice

Kippax Hall Surgery

Lofthouse Surgery

Moorfield House Surgery

Nova Scotia Medical Centre

Oulton Medical Centre

Applicants must be available to work on Wednesdays as this is an essential requirement for the role.

Main duties of the job

Our Care Coordinators will play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They will be working closely with practice and PCN staff to identify, engage with and proactively coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, people living with severe mental illness or learning disabilities, and those with long-term health conditions.

As well as being linked with individual practices they will work together as a team. This will include sharing learning and best practise both within the team and across the PCN.

Support with patient engagement, which will include ensuring that information is accessible for all and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.

To support people in preparing for or following-up clinical conversations they have with primary care professionals (including health checks) to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.

See attached.

Job description

Provide admin support to multidisciplinary meetings including taking minutes.

Utilise GP Practice clinical systems (SystmOne) and population health data to proactively identify relevant cohorts of patients to deliver personalised care.

Support patients within these cohorts to access health checks and other health services.

Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations.

Assist patients and carers in managing their own needs, answering their queries and supporting them to address their needs.

Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding.

Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care.

Raise awareness of shared decision making and decision support tools, and assist patients to be more prepared for shared decision making conversations.

To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN.

Work in partnership with key providers in the local community to enable improved access to services for patients.

Work with practices to support delivery of any national and local targets with regard to the GP contract e.g. PCN DES and I&IF.

Support the delivery of the E-Falls Pilot Scheme, including identifying eligible patients, contacting patients, coordinating appointments, monitoring engagement, and maintaining accurate records.

Coordinate administration for Extended Access Saturday Clinics, including contacting patients to confirm attendance and manage cancellations.

Support DOAC (Direct Oral Anticoagulant) Clinics by sending patient questionnaires, monitoring responses, booking patients into clinics where required, and ensuring timely follow-up.

Provide administrative support for the Leg Club Service by accurately updating and maintaining patient records with information received from Leg Club appointments and interventions.

Support the delivery of GLP-1 Weight Management Clinics, including contacting patients, arranging appointments, recording heights and weights, coordinating blood tests, maintaining accurate records, and supporting ongoing patient monitoring.

Personal & Professional development

Maintain continued education by attendance at courses as deemed essential for professional development.

Participation in annual appraisal review.

Maintaining a record of own personal and/or professional development.

See attached for more information.

About us

We are a dynamic, forward thinking PCN team who are passionate about developing and delivering excellent quality local services to meet the needs of our patients. Please have a look at our website to find out more about our team, projects, services and partners. (www.ls2526pcn.co.uk)

We are very excited to be recruiting another Care Coordinator to join our PCN team. We currently have 6 Care Coordinators, and the rest of our PCN staff include pharmacists, pharmacy technicians, trainee pharmacist, paramedics, Health Care Assistant/Social prescribers (doing home visits and support for housebound patients), health and wellbeing coach, physiotherapists, admiral (dementia) nurse and nurse associate.