PCN Care Coordinator

The Respiratory Care Co-ordinator will work as an integral part of the PCN's multidisciplinary team (MDTs), working alongside the Social Prescribers and the Health and Wellbeing Coaches to provide an all-encompassing approach to personalised care, and promoting and embedding the personalised care approach across the PCN. They will be based within both Practices within it. The post holder will: 1. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload of patients with respiratory conditions, and where appropriate, refer back to other health professionals within the PCN. This will involve regularly running reports from our clinical systems i.e. EMIS. 2. Assist the Respiratory Nurses to provide person centred health care to all patients with respiratory conditions or respiratory symptoms requiring medical intervention within the PCN. 3. Assist the Practices in meeting associated respiratory targets set by the Directed
Enhanced Service (DES), Quality & Outcomes Framework (QOF) and Impact and Investment Fund (IIF) as required 4. Safely administer patients respiratory reviews and co-ordinate appropriate healthcare, within the limitations of the role, in a timely manner 5. Participate if/as required in the daily and weekly Multi-Disciplinary Team (MDT) One Team meetings with the PCN team and community services. 6. Provide co-ordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals to help ensure patients receive a joined-up service and the most appropriate support. 7. Work with people (or their families and carers if required) to improve their understanding of their condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. 8. Actively support and administer Group
consultations/events for patients as and when required. 9. Review and update personalised care and support plans at regular intervals and ensure these 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 (system) codes. 10. Support Practices to keep care records up-to-date and accurate by identifying and updating missing or out-of-date information about the persons circumstances. 11. Maintain records of referrals and interventions to enable monitoring and evaluation of the service. 12. Ensure that allocated patients are able to access services available in the community both free and where charges apply - based on the Co-ordinators detailed knowledge of the relevant access arrangements, eligibility criteria and service content. To connect the services that already exists locally both statutory and voluntary, so that services wrap-around the patient. 13. Help
people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Refer onwards to social prescribing link workers and health and wellbeing coaches where required. 14. Assist people to access an assessment for Adult Social Care where appropriate, and provide information in connection with personal budgets. 15. Conduct follow-ups on communications from out of hospital and in-patient services. 16. Support the PCN in developing communication channels between GPs, people and their families and carers and other agencies. 17. Contribute to risk and impact assessments, monitoring and evaluations for quality improvement of the service. 18. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations. 19. Take referrals
for individuals or proactively identify people who could benefit from support through care co-ordination.