Care Coordinator (PCN)

Key responsibilities Work with people, their families and carers, to improve their understanding of their condition. Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health. Provide co-ordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other primary care
professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN. Support the co-ordination and delivery of multidisciplinary teams with the PCN. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations. Explore and assist people to access a personal health budget where appropriate. Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours. Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies. Identify carers and help them access services to support them. Conduct follow-ups on communications from out of hospital and in-patient services. Maintain records of referrals and interventions to
enable monitoring and evaluation of the service. Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances. Contribute to risk and impact assessments, monitoring and evaluations of the service. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation. Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care co-ordination on their health and wellbeing. Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. 1. Enable access to personalised care and support a. Take
referrals or proactively identify people who could benefit from support through care co-ordination. b. Have a positive, empathetic and responsive conversations with people and their families and carer(s), about their needs. c. Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance. d. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them. e. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly. f. Support people to develop and implement personalised care and support plans. g. Review and update personalised care and support plans at regular intervals. h. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant
online care records, with activity recorded using the relevant SNOMED codes. i. Where a personal health budget is an option, work with the person and the local ICS team to provide advice and support as appropriate. 2. Co-ordinate and integrate care a. Make and manage appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations. b. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system. c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need. d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or
concerns can be appropriately addressed and supported. e. Actively participate in multidisciplinary team meetings in the PCN. f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. g. Record what interventions are used to support people, and how people are developing on their health and care journey. Please note this list of duties is not exhaustive.