Care Coordinator in Primary Care Network

This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to take into account development within the North Halifax PCN. All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the organisation. This list may be amended, following consultation with the post-holder, to facilitate the development of the role, the Network and the individual. Main Duties: Undertake responsibilities in line with the PCN DES and focus on the delivery of the PCN care model to reflect local priorities, health inequalities and population health management providing a point of contact to facilitate continuing care requirements Bring together all of a persons identified care and support needs and what matters to them Provide coordination
and navigation for individuals and their carers across health and care services, working closely with the PCN team Support the coordination and delivery of multidisciplinary work streams within the PCN Build and maintain relationships within the Network, including staff at member practices, to encourage best practice and outcomes Work in partnership with the PCN and practice teams to provide extra capacity, resource, and expertise to support North Halifax patients preparing for and following-up clinical interventions Work closely with other health and social care professionals to identify and support patients making sure that access to appropriate services is available to them and ensuring that their needs are met Proactively identify and work with NH PCN patients to support their personalised care needs. Help people to manage their needs, answer their queries and support them to make and attend appointments Ensure that people have good quality information to help them make choices about
their care Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing Consult with patients and family members to discuss their health needs where appropriate Signposting support to patients/family/care home on information about patient condition(s) Provide coordination and navigation for people and their carers across health and care services, alongside working closely with the Social Prescriber Link Workers and other primary care roles. Maintain accurate and contemporaneous patient records at all times Raise and report issues/concerns and monitor until a resolution is achieved Demonstrate flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner. Work on rotation with the other care coordinators to provide in person
guidance to patients coming to our new premises in Mixenden Hub