PCN - Care Coordinator

An exciting opportunity has arisen for a Care Coordinator in the organisation, who must be available to work on a full-time basis with flexibility when required to work across sites within PCNs. Practices across Waltham Forest have come to work collaboratively as Primary Care Networks (PCNs), pooling their resources and workforce to provide improved and integrated services for their patients. PCNs typically consist of 30,000-50,000 patients. Main duties of the job Work withinour network of GP Practices to provide a central co-ordination role for patientcare planning. The role will be GP facing, with the core responsibility beingexcellent patient care. Co-ordinatecare packages for patients as identified by the GP across health, social careand mental health as appropriate, providing a single-point of access for staff& service users, actively managing patients care plan delivery Facilitatesmooth and planned discharge and handover between care settings across thehealth and social care system, including GP, acute, community, and beresponsible for facilitating inter-agency communication and support Identifyand work with a list of named patients with the aim of encouragingindependence, enabling people to remain at home, reducing unnecessaryadmissions to hospitals and supporting early discharge from hospital, improvingthe quality of care., 1. Facilitate and ensure the effective delivery of patient-centred,personalised health and social care plans for patients, monitoring progress andreporting outcomes, contributing to patient reviews and care planning withinappropriate time frames 2. Explain the management of a patients pathway to clinical staff,liaising between services and service users, contacting services using theappropriate procedures / referral mechanisms 3. Workclosely with all relevant care agencies (primary care, secondary care, communityservices, Mental Health, Social Services, Ambulance Service, Voluntary servicesand other relevant service providers) to ensure a coordinated and of thepatients care plan, without requiring a further referral from the GP. 4. Maintain accurate records and statistical returns as required bythe CCG, including providing patient-related information for entering intoClinical Reporting Systems, within the required time frame. 5. Ensure that a proper handover of care between different settingshas taken place, including mutual transfer of all organisations communications& patient notes and ensuring care packages are set up 6. Collect data on patients / carers for recognised outcome measure anddocument for service interpretation. Ensure all patient notes are updated toreflect any changes, including details on plans 7. Managing operational meeting processes, identifying patients fordiscussion and working closely with clinicians to define and lead the meetings.Organise and attend relevant meetings when required including Integrated Caremeetings, ensure a programme of regular meetings is established, ensuring thatall necessary documentation is circulated in advance 8. Ensure that meeting actions are recorded, disseminated andfollowed up in a timely way; ensure relevant practitioners are aware of meetingdecisions and actions / outcomes, and chase for action resolution and update. 9. Network and develop strong relationships with all levels of theNHSs key local players including the CCG, GPs and other primary carecontractors, Social Services, Mental Health Trusts, Community Trusts, and otherproviders including the voluntary sector Be a contact point for GPs / practices and establish systems andprocesses which will ensure a timely and appropriate response to queries fromclinicians and other stakeholders

Essential

• Relevant degree or equivalent level of training and experience
• Evidence of a consistent pattern of learning from education, training and experience
Desirable
• Qualification in health or social care allied profession
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WF GP FedNet is a not-for-profit Federation of 36 GP Practices in Waltham Forest. We are a private limited company who provides NHS Services based in Primary Care, pooling the skills and resources of local GPs to provide large scale services as part of the local NHS Strategy to bring more services into the Community to help people stay well and at home