Bury St Edmunds PCN has an opportunity for a care coordinator to join our primary care network (PCN), to support one of our five GP practices across the Bury area. The role is offered on a full-time basis of 37.5 hours over 5 days per week, primarily Monday and Friday, between the hours of 0830 and 1800hrs, with some weekend hours required subject to demand. We can consider 30+ hours for the right applicant.
The role involves working very closely with the practice and the multidisciplinary team (MDT) and also within the wider PCN. The role is pivotal in ensuring that all patients receive the best possible care and service, working on requirements for the PCN Direct Enhanced Service Contract (DES).
Our care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
Primary responsibilities of the role will include:
- Work with people, their families and carers to improve their understanding of the patients’ condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
- 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.
- Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
- Support the coordination and delivery of multidisciplinary teams with the PCN.
- 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.
- Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies.
- Maintain records of referrals and interventions to enable monitoring and evaluation of the services.
- Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the person’s circumstances.
- Contribute to risk and impact assessments, monitoring and evaluations of the service.
- Work with commissioners, integrated locality teams and other agencies to support and further develop the role.
Please see attached job description for more details.