Job description

Job responsibilities

Coordinate patient communication and outreach

• Support the network in developing communication channels between GPs, people and their families and carers and other agencies.
• Manage the PCNs social media channels and websites
• Coordinate the PCN Patient Participation Group
• Coordinate events focussed on improving health and access to health and care that brings together patients, community assets and the network
• Develop and implement interventions to decrease barriers to accessing primary care services for people facing health inequalities
• Support the wider work of the PCN and understand the various workstreams taking place across the network

• Work with the lead of the proactive care team, GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN. This patient population includes but is not limited to persons who are unable to leave their homes or require significant assistance to leave the house due to illness, frailty, surgery, mental ill health or nearing end of life.
• Organise and actively participate in multidisciplinary meetings of the proactive care team
• Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
• 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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health
• Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns
• Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances

Enable access to personalised care and support

• Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them
• Assist people to access self-management education courses, peer support or interventions that support them to take more control of their health and wellbeing
• Explore and assist people to access personal health budgets where appropriate
• Support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers
• 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
• Raise awareness within the PCN of shared decision-making and decision support tools; and
• Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.

• Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required
• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety

Miscellaneous

• Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team
• Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner
• Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning
• Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities
• Contribute to the wider aims and objectives of the PCN to improve and support primary care
• Aid implementation of the seasonal vaccination programmes such as COVID-19 and influenza

Job responsibilities

Coordinate patient communication and outreach

• Support the network in developing communication channels between GPs, people and their families and carers and other agencies.
• Manage the PCNs social media channels and websites
• Coordinate the PCN Patient Participation Group
• Coordinate events focussed on improving health and access to health and care that brings together patients, community assets and the network
• Develop and implement interventions to decrease barriers to accessing primary care services for people facing health inequalities
• Support the wider work of the PCN and understand the various workstreams taking place across the network

• Work with the lead of the proactive care team, GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN. This patient population includes but is not limited to persons who are unable to leave their homes or require significant assistance to leave the house due to illness, frailty, surgery, mental ill health or nearing end of life.
• Organise and actively participate in multidisciplinary meetings of the proactive care team
• Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
• 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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health
• Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns
• Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances

Enable access to personalised care and support

• Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them
• Assist people to access self-management education courses, peer support or interventions that support them to take more control of their health and wellbeing
• Explore and assist people to access personal health budgets where appropriate
• Support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers
• 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
• Raise awareness within the PCN of shared decision-making and decision support tools; and
• Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.

• Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required
• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety

Miscellaneous

• Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team
• Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner
• Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning
• Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities
• Contribute to the wider aims and objectives of the PCN to improve and support primary care
• Aid implementation of the seasonal vaccination programmes such as COVID-19 and influenza

Person Specification

Qualifications

Essential

• Willingness to undertake, undertaking or qualified from appropriate training as set out in Workforce Development Framework for Care Coordinators by the Personalised Care Institute
• Educated to GCSE or A Level Standard in English and Maths
• Proficient in MS Office and web-based services

Desirable

• Qualified to NVQ Level 3 in Health and Social Care

Experience

Essential

• Experience of communications and content creation
• Experience of working within multi-professional team environments
• Experience of data collection and using tools to measure the impact of services

Desirable

• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience in coordination and planning of events
• Experience or training in personalised care
• and support planning
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Personal Qualities and Attributes

Essential

• Ability to actively listen, empathize with people and provide personalized support in a non-judgmental way
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
• Ability to identify risk and assess / manage risk when working with individuals
• Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
• Ability to work from an asset-based approach, building on existing community and personal assets
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• Ability to demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety

Skills and Knowledge

Essential

• Ability to communicate effectively and professionally with colleagues and patients from a wide variety of healthcare professions, backgrounds and diverse groups
• In depth knowledge of social media platforms such as Facebook, Instagram and X
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Ability to recognise and work within limits of competence and seek advice when needed

Desirable

• Effective use of social media platforms such as Facebook, Instagram and X to communicate messages on behalf of an organisation
• Knowledge of the personalised care approach
• Knowledge of how the NHS works, including primary care and PCNs
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social
• Familiarity with EMIS clinical software

Other

Essential

• Meets DBS reference standards and criminal record checks
• Willingness to work flexible hours when required to meet work demands
• Ability to travel across the locality on a regular basis

Desirable

• Access to own transport
• Proficient speaker of another language to aid communication with people in a community for whom English is a second language

Qualifications

Essential

• Willingness to undertake, undertaking or qualified from appropriate training as set out in Workforce Development Framework for Care Coordinators by the Personalised Care Institute
• Educated to GCSE or A Level Standard in English and Maths
• Proficient in MS Office and web-based services

Desirable

• Qualified to NVQ Level 3 in Health and Social Care

Experience

Essential

• Experience of communications and content creation
• Experience of working within multi-professional team environments
• Experience of data collection and using tools to measure the impact of services

Desirable

• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience in coordination and planning of events
• Experience or training in personalised care
• and support planning
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Personal Qualities and Attributes

Essential

• Ability to actively listen, empathize with people and provide personalized support in a non-judgmental way
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
• Ability to identify risk and assess / manage risk when working with individuals
• Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
• Ability to work from an asset-based approach, building on existing community and personal assets
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• Ability to demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety

Skills and Knowledge

Essential

• Ability to communicate effectively and professionally with colleagues and patients from a wide variety of healthcare professions, backgrounds and diverse groups
• In depth knowledge of social media platforms such as Facebook, Instagram and X
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Ability to recognise and work within limits of competence and seek advice when needed

Desirable

• Effective use of social media platforms such as Facebook, Instagram and X to communicate messages on behalf of an organisation
• Knowledge of the personalised care approach
• Knowledge of how the NHS works, including primary care and PCNs
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social
• Familiarity with EMIS clinical software

Other

Essential

• Meets DBS reference standards and criminal record checks
• Willingness to work flexible hours when required to meet work demands
• Ability to travel across the locality on a regular basis

Desirable

• Access to own transport
• Proficient speaker of another language to aid communication with people in a community for whom English is a second language

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

Childwall and Wavertree Primary Care Network

Address

75 Hartsbourne Avenue

Liverpool

L25 1RY

Employer's website

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