PCN Care Coordinator

You will be responsible for coordinating, integrating and delivering support to practice patients. You will work with colleagues, patients, their families and carers, to improve their health and wellbeing by navigating them to the appropriate services. Ensure they have good quality information to support their decision making.

You will guide them to access these services and any appropriate funding that is available to support them, including access personal health budgets where appropriate.

All aspects of project work and working with Neighborhood Health Projects , the projects may be targeted at specific patient groups, identified by GP practices. These patients will include but are not limited to adults with complex long term health needs, depression, organic mental illness, and those who are at risk of social isolation.

You will work collaboratively with the general practice teams, including social prescribing link workers, to meet the needs of patients and to support the delivery of the Primary Care Network responsibilities and objectives.

You will work collaboratively with the general practice teams, to meet the needs of patients and to support the delivery of the Primary Care Network responsibilities and objectives.

You will work closely with the PCN Manager and the PCN team, patients, families and carers, to improve their health and wellbeing by navigating them to the appropriate services. Ensure they have good quality information to support their decision making, take a holistic approach, bringing together all of their identified care and support requirements into a single personalised plan based on what matters most to the patient.

This could include access to peer support or interventions that assist them in their health and wellbeing as well as supporting patients.

This is done using a single point of access system and working closely with the practices and care homes.

You will bring together the patients identified care and support needs and explore with them, their options to meet these into a single personalised care and support plan (PCSP).

All aspects of project work will need to be undertaken including Neighborhood Health Projects, this service may be targeted at specific patient groups, identified by GP practices. These patients will include but are not limited to adults with complex long term health needs, depression, organic mental illness, and those who are at risk of social isolation.

You will be involved in daily data entry, rota planning and administration to ensure the clinical systems and are all up to date.

You will be asked to cover Enhanced Access to support the practices with clerical issues and work, this will include some evening and Saturday morning work.

Cygnet

PCN covers a large geographical area within the East Riding of Yorkshire. Our network covers over 51,000 patients and is made up of the five following GPPractices:

Bartholomew Medical Group

Snaith & Rawcliffe Medical Group

Montague Medical Practice

Howden Medical Centre

Our network comprises of a range of roles from Clinical Director to Care Co-ordinator.

PCN's build on existing primary care services and enable greater provision of proactive, personalised, coordinated and more integrated healthand social care for people close to home. Our PCN are proactively providing care and services for the people and communities we serve.

Newroles are being introduced to the network as we are expanding into different areas of Healthcare.

The network provides a single point of access for the nursing, residential and learning disability homes in the area.

Allour team are passionate and committed to making a difference to patient care.

• Working towards achievement of PCN directedpriorities (e.g. Coordination of system widecare within our local Care Homes and other aspects of Primary Care as necessary).
• Proactively identify and work with cohorts of patients to coordinate and navigate the support necessary for their personalisedcare requirements
• Work on PCN wide projects to tackle health inequalities through the Neighborhood Health Partnership
• Ensure that patients have good qualityinformation to help them make informed choices about their care
• Ensure regular and consistent communication with the patient, referrer and wider care system regarding patient progress andany complications or guidance
• Coordinate and support PCN training days and work closely with the PCN Manager
• Within the scope of PCN priority areas data entry is crucial, you will monitor data to ensure tasks are completed and care delivered in line with national timelines.
• Liaise with multi agencies to coordinatepathways of care for patients across local services, colleagues and the practices.
• Support Quality and Outcome Frameworks (QoF) and other National and Local targets of best practice.
• Work within all policies and proceduresensuring that individual's and carers' information remains confidential
• Provide accurate and timely performancereporting within the…