Cross Gates PCN Care Coordinator

Cross Gates Primary Care Network includes four practices working across seven sites: Ashfield and The Grange Medical Centre, Colton Mill and The Grange Medical Centre, Family Doctors and Manston and Surgery. The PCN has a patient population of 30,000 including patients living across 5 care homes.

We believe in providing a holistic approach to managing patient care and supporting individuals to meet their own needs and aspirations. You will be part of an organisation whose leadership team are supportive and innovative, focused on change and transforming services.

Our team currently includes pharmacists, pharmacy technician, mental health practitioners, advanced clinical practitioner, admiral nurse, nurse associate, physician associate, first contact physiotherapists, health and wellbeing coaches and care coordinators, with the aim of supporting our practices and improving health outcomes for our patients. We do this through the integration of PCN teams and services with our practices, continuous evaluation, and ongoing development of our services and projects, looking for opportunities for innovation and transformation and sharing best practice., Our Care Coordinators play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They work closely with practice and PCN staff to identify, engage with and coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, patients with dementia and their carers, patients diagnosed with cancer, care home residents and those with long-term health conditions.

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

Our Care Coordinators support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings including weekly Care homes meetings.

About us

They run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, vaccinations and other services including self-management services. Support with patient engagement, which includes 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.

They support people in preparing for or following-up clinical conversations 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.

Care Coordinators act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.