Pcn Care Coordinator

As a PCN Care Coordinator, you will work closely with member practices and the PCN in offering a personalised approach to caring for social and psychological needs of identified patients on your caseload, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. You will also support other ARRS roles in delivering PCN DES by contributing towards projects on an ad hoc basis to support health improvements to patients registered with member practices. Your main duties will include: Receiving and actioning referrals from a wide range of agencies, working with GP practices within the Primary Care Network (PCN), pharmacies, multi-disciplinary teams, hospital discharge teams and allied health professionals (list not exhaustive); Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care; Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames; Provide coordination and navigation for patients and their carers across the spectrum of services available; Support local Care Homes to manage patient needs, including completing/reviewing Care Home Care Plans and Dementia reviews as required, contributing to Care home ward rounds Complete Annual Learning Disability reviews on behalf of the practice; Undertake visits to see patients in their own homes, where applicable, for Blood Pressure checks, welfare checks and provide support; Work alongside other PCN Additional Roles staff and outside agencies to provide wrap-around support to patients; Make appropriate third-party referrals; and Complete and maintain accurate patient records. This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to consider development within the practices. The post holder should be prepared to take on additional duties or relinquish existing duties to maintain the efficient running of the Network. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder. The roles involves travelling to PCN member practices as required for the service delivery.