PCN Care Co-ordinator

Morley and District Primary Care Network have an exciting opportunity for an experienced care co-ordinator to join their team.

This is a important role that will help shape and form the layout of our local healthcare offer in Morley, Leeds.

The suitable candidate should be passionate about making a difference in primary care and enjoy working as part of a multi-disciplinary team across services.

Care co-ordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly andthose with long-term conditions, to provide co-ordination and navigation ofcare and support across health and care services.

They work closely with GPs and practice teams to manage acaseload of patients, acting as a central point of contact to ensure appropriate support is made available to people and their carers; supporting them to understand and manage their condition and ensuring their changing needsare addressed.

This is achieved by bringing together all the information about a persons identified care and support needs and exploring options tomeet these within a single personalised care and support plan, based on what matters to the person.

Care co-ordinators could provide time, capacity and expertise to support people in preparing for, or following-up, clinical conversations. Enabling them to be more actively involved in managing theircare and supporting them to make choices that are right for them.

We are looking for a care coordinator to work on our population health management needs, this may involve been in the community talking to patients and managing their care.

Key responsibilities

Work with people,their families and carers, to improve their understanding of their condition.

Support people to develop andreview personalised care and support plans to manage their needs and achieve better healthcare outcomes.

Work with people,their families, carers and healthcare team members to encourage effective help-seeking behaviours.

Support PCNs in developing communication channels between GPs, people and their families andcarers and other agencies.

Help people tomanage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.

Provide co-ordination and navigation for people and their carers across health and care services. Helpingto ensure patients receive a joined-up service and the appropriate support fromthe right person at the right time.

Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients withlong-term health conditions, and where appropriate, refer back to other health professionals within the PCN.

We are a 6 practice PCN with approximately 65,000 patients. We are rapidly developing our multi-disciplinary workforce, embedding our roles, developing our team that makes a real difference to our patients and our practices. we pride ourselves on tackling the needs of our patients by working together to provide personalised health support for our population health needs.

Morley is a thriving area of South Leeds with a strong community. The area is a highly sought after place to live due to its excellent links to the city and busy town centre.

We would Welcome applicants who have a strong admin and people background.

Enable access to personalised care and support

Take referrals or proactively identify people whocould benefit from support through care co-ordination.

Have a positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.

Increasing patients understanding of how to manageand improve health and wellbeing by offering advice and guidance.

Develop an in-depth knowledge of the local healthand care infrastructure and know how and when to enable people to access support and services that are right for them.

Use tools to measure peoples levels of knowledge,skills and confidence in managing their health and tailor support to them accordingly.

Support people to develop and implement personalised care and support plans.

Review and update personalised care and support plans at regular intervals.

Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person scare and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.

Co-ordinate and integrate careMake and manage appointments for patients, relatedto primary, secondary, community, local authority, statutory, and voluntary organisations.

Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system.

Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical…