Care Coordinator – Taunton Deane West PCN

Taunton Deane West - Primary Care Network

JOB DESCRIPTION and PERSON SPECIFICATION

Job Title

Care Coordinator with a Lead on patients recently discharged from hospital or attending hospital

Responsible To

Clinical Director (CD) and Clinical Lead

Job purpose

To develop and deliver the ambition of the PCN to have a robust and effective Care Coordinator activity with a lead on supporting patients recently discharged from hospital or attending hospital/A+E and any routine admin, to plan, drive and develop the service delivery through collaboration within the PCN.

Pay/Hours

Annual leave entitlement:

£21,892 – £24,157 per annum full time (37.5 hours a week)

25 days annual leave entitlement + bank holidays

Job summary

The Care Coordinator will work with the PCN TDW team supporting them to review holistically patients recently discharged from hospital or attending hospital/A+E and any routine admin. This is a pivotal role and is required to support multidisciplinary teams and coordinate the pathway for patients.

As a patient-facing role, the post holder will also be responsible for a caseload of patients identified via the three practices. Support provided directly with patients and their carers would include supporting the development of personalised plans, utilising decision aids, providing information and training opportunities, making appointments, coordination and navigation for people and their carers across health and care services.

In addition to the patient facing responsibilities, the Care Coordinator will support the pharmacists with structured medication reviews and reviewing patients recently discharged from hospital with new medications/change in medication.

Key Responsibilities

Ensure that all patients are contacted on discharge from hospital, their current needs are reviewed, and further support and signposting offered.

To bring those patients relevant to the MDTs for further discussion and support.

Be responsible for contacting patients who may have attended A+E inappropriately as a way of managing their long-term condition and review their needs and support them to engage with the GP practice.

Direct patient facing work

Manage a caseload of patients identified via the three practices

Support patients to manage their medications and social needs on discharge.

Holistically bring together all of a person’s identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.

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.

Support people to take up training and employment, and to access appropriate benefits where eligible.

Support people to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure.

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.

Explore and assist people to access personal health budgets where appropriate.

Communication and collaborative working relationships

Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.

Liaise with other stakeholders as needed for the collective benefit of patients including but not limited to Patient’s GP, Nurses, Pharmacists other practice staff and other healthcare professionals including Care Coordinators. Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, Regional Screening Team, Cancer Alliances, Macmillan Cancer Support, Adult Social Care, Hospitals, Community Pharmacists and other members of the MDT.

Meet regularly with the Clinical Lead and review caseload and MDT function.

Keep the PCN aware of ‘good news’ stories.

Provide background information about individuals for the regular MDT meetings.

Communicate effectively with service users and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals.

Manage and prioritise workload on a daily basis.

Job Spec - Care Coordinator with a Lead on patient review from hospital.docx