Job description

Job responsibilities

Job purpose

The PCN Care Co-ordinator will provide practical personalised support to patients whose care involves several professionals or services

The postholder will help patients understand the next steps in their care communicate what matters to them and access the support agreed with their clinical team

The postholder will maintain a defined caseload coordinate appointments and referrals follow multidisciplinary team actions through to an outcome and raise concerns promptly

The Care Co-ordinator will work across Bradford City Five PCN member practices and with the wider PCN multidisciplinary team

Patient care and co-ordination

Use clinician-approved patient lists practice referrals and multidisciplinary team recommendations to identify and engage patients requiring care co-ordination

Contact patients using agreed methods explain the service and identify their priorities communication needs and any barriers to accessing care

Maintain an accurate and current caseload including contact dates next actions responsible professionals review dates and outcomes

Help patients prepare for conversations with GPs nurses pharmacists and other healthcare professionals

Support patients to understand agreed actions and personalised care and support plans ensuring they know who is responsible for each action and what happens next

Arrange and track agreed appointments referrals and reviews and help resolve practical barriers that may prevent patients from accessing care

Follow up missed appointments and contacts in accordance with agreed PCN and practice procedures

Support access to appropriate self-management wellbeing and community services working closely with the PCN Social Prescribing and Health and Wellbeing teams

Supporting priority patient groups

The postholder will support agreed PCN patient cohorts which may include people with long-term conditions and complex needs

This will include supporting patients living with frailty or dementia and their carers to prepare for reviews and ensuring agreed actions are followed up

The Care Co-ordinator may also support patients experiencing repeated urgent-care use recent transitions of care difficulties attending appointments or other barriers to accessing healthcare

The postholder will support agreed screening vaccination and annual-review activity for patients within their caseload where appropriate

Multidisciplinary team working

Support the organisation and co-ordination of relevant patient multidisciplinary team discussions

Ensure appropriate information is available to support multidisciplinary team discussions through approved secure processes

Where possible establish the patient's priorities before their case is discussed

Accurately record agreed actions including the responsible professional and expected completion date

Track outstanding actions and escalate overdue or rejected referrals appropriately

Keep patients appropriately informed about agreed actions and follow-up

Work collaboratively with GPs nurses practice teams Social Prescribing Link Workers Health and Wellbeing Coaches Clinical Pharmacists mental health professionals physiotherapists and relevant community and voluntary-sector services

Record keeping and information governance

Document patient contacts and actions promptly and accurately in SystmOne using agreed PCN and practice templates and codes

Maintain confidentiality and comply with PCN and practice information governance data protection and information-sharing requirements

Use authorised systems and accounts and only access or share information necessary for the role

Verify identity and appropriate carer authority before sharing confidential patient information

Provide appropriate anonymised or aggregated activity and outcome information to support PCN monitoring and service development

Safety safeguarding and role boundaries

This is a non-clinical role

The Care Co-ordinator will not diagnose conditions independently assess clinical urgency prescribe medication interpret test results or make changes to a patient's treatment

Promptly escalate new symptoms deterioration medication concerns or other clinical concerns to an appropriate clinician

Recognise and respond appropriately to safeguarding concerns following local safeguarding procedures

Use urgent or emergency escalation routes where required in accordance with local procedures

Maintain clear factual records of concerns and actions taken

Work within their level of competence and seek advice or supervision whenever a task or situation falls outside their role

Follow relevant health and safety infection prevention equality accessibility incident reporting and lone-working procedures

Working with our communities

The postholder will work respectfully and sensitively with Bradford's diverse communities

They will identify patients' preferred language communication method accessibility requirements and safe contact arrangements

The postholder will use professional interpreting services through agreed routes where required

The Care Co-ordinator will recognise that some patients may experience digital exclusion or other barriers to accessing healthcare and will support appropriate alternative methods of communication and access

Training and development

Complete an appropriate induction programme and all required mandatory training

Undertake or complete the appropriate Care Co-ordination training pathway

Participate in regular supervision appraisal and continuing professional development

Maintain an appropriate learning and development record

Attend relevant PCN practice and multidisciplinary meetings

Identify opportunities to improve patient pathways and reduce barriers to accessing care

Contribute to patient and practice feedback and service improvement

Service development

The postholder will help colleagues understand the Care Co-ordination referral pathway and appropriate use of the service

They will contribute to the development of safe and effective processes for managing referrals caseloads multidisciplinary team actions follow-up and handover arrangements

The role will continue to develop in response to the needs of patients and the PCN

Any additional duties will be reasonable and consistent with the purpose level training and responsibilities of the Care Co-ordinator role

Management and accountability

The postholder will report to the PCN Manager and work within the governance arrangements of Bradford City Five PCN Limited

The postholder will receive named Care Co-ordination supervision and have access to appropriate clinical support and escalation routes

The role will work across the Bradford City Five PCN member practices and agreed community settings

Person Specification

Qualifications

Essential

• Relevant Level Three qualification or equivalent skills and experience
• Willingness and ability to undertake and complete the appropriate Care Co-ordination training pathway.
• Experience of supporting patients service users or carers within healthcare social care or a community setting
• Experience of coordinating appointments referrals or multi-step work and following actions through to completion
• Experience of maintaining accurate records and managing confidential or sensitive information
• Experience of organising and prioritising a workload and working with different professionals or services

Desirable

• Experience of working within general practice a Primary Care Network or the NHS
• Experience of using SystmOne or another electronic patient record or case management system
• Experience of supporting people with frailty dementia long-term conditions or inclusion health needs
• Experience of supporting multidisciplinary team working personalised care plans or service improvement

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

The Bradford Moor Practice

Address

Barkerend Health Centre

Barkerend Rd

Bradford

West Yorkshire

BD3 8QH

United Kingdom

Employer's website

https://bradfordmoorpractice.co.uk/ (Opens in a new tab)