PCN Care Coordinator

Are you an innovative person with excellent interpersonal and communication skills and would love the exciting challenge of working within a developing patient-focused service, consistently approaching patients with empathy, then this could be the job for you., Population Health Management (PHM) care coordinator will work across their respective PCN to support the delivery of the Population Health Management Programme. This programme is focussed on providing more proactive support to people over 65 with mild/moderate frailty. This is an exciting time to join either Oldham South or Oldham North PCN in the progression and development of the Primary Care Networks and this pivotal role in delivering a pioneering health improvement programme. The role will involve supporting the ongoing identification, engagement and case management of over 65s with mild/moderate frailty, to intervene early to maintain good health, prevent deterioration and ensure they are able to access services which meet their range of needs. The role will work within one of the PCN teams and across an integrated neighbourhood team of different health and care professionals involved in the care of this group of patients to coordinate their care plans., This role involves patient facing care, and the post holder will be responsible for providing support directly to patients and their carers. The post holder will also act as a conduit for patients within the PCN, liaising with GPs, district nurses, therapists, physios, adult social care, voluntary sector, and other PCN colleagues.

Actively develop effective working relationships and lines of communication within the practice, with the PCN, and with wider multi-professional teams across South e.g. Social Prescribers, Pharmacists and other clinical/non-clinical partners involve in the patients care

Demonstrates ability to work effectively as a member of a team with the practice, PCN and ANP as a key person within the PHM model.

Can recognise personal limitations and refer to more appropriate colleague(s) when necessary.

Follow through with service users and others involved to ensure all services and care arrangements are in place.

Develops an in-depth knowledge of local health and care infrastructure and knows how and when to enable people to access support and services that are right for them.

Oldham South PCN and Oldham North PCN are looking to hire 2 full-time posts one in in each PCN.

Oldham South Primary Care Network (PCN) is a network of 5 GP Practices within the Oldham Integrated Care System. Oldham South PCN services a population of around 43,000 patients.

Oldham North Primary Care Network (PCN) is a network of 4 Practices within the Oldham Integrated Care System. Oldham North PCN services a population around 42,000 patients.

As PCNs, we are looking to grow our team of professionals focusing on a new population health management programme, to support more proactive and holistic care for people with mild to moderate frailty in our locality.