Lowestoft PCN Care Co-Ordinator

Job responsibilities Main duties of the job Care Coordinators support patients in preparing for or following up on clinical conversations with healthcare professionals. They work closely with GPs and other primary care colleagues to ensure that patients receive personalised care and support to proactively manage their health. This varied role will involve gathering relevant information and data about a patients health to support review appointments, preparing personalised care plans and liaising with the Social Prescribing Link Workers to ensure patients can access non-clinical support in the community. Patients are contacted by a variety of methods including email, other electronic access systems, letters, telephone, video or face to face contact. The Care Coordinator will be involved in triage, sign posting and care navigation of patients. Primary Duties and Areas of Responsibility Support practices to deliver their quality improvement plans for early cancer diagnosis. Develop and embed
systems across the network to improve cancer screening uptake, liaising with external agencies as appropriate Utilise population health intelligence to proactively identify and work with patients newly diagnosed with cancer and on the cancer register to deliver personalised care; Ensure patients receive a Cancer Care review in line with national defined timescales and targets. Support the practices in your practice/PCN in conducting peer to peer learning events that look at data and trends in diagnosis across the practice/PCN, including cases where patients presented repeatedly before referral and late diagnoses Support patients to utilise decision aids in preparation for a shared decision-making conversation Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person 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 Support people to take up training and employment, and to access appropriate benefits where eligible Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level Explore and assist people to access personal health budgets where appropriate Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals Support the coordination and delivery of MDTs within the practice/PCN Work with the GPs and other primary care professionals within the
practice/PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the practice/PCN Raise awareness within the practice/PCN of shared decision making and decision support tools Raise awareness of how to identify patients who may benefit from shared decision making and support practice/PCN staff and patients to be more prepared to have shared decision-making conversations Safeguard patients by ensuring organisations and groups to whom its Care Coordinator directs patients have basic safeguarding processes in place for vulnerable individuals and provide opportunities for the patient to develop friendships and a sense of belonging, as well as to build knowledge, skills and confidence