Job description

Job responsibilities

We do not provide visa sponsorship

JOB SUMMARY

The PCN Care Coordinator will provide proactive, person-centred coordination and practical support to patients and carers registered with Havering Liberty PCN practices. The post holder will work across the Primary Care Network to improve access, communication, continuity and follow-up, helping people navigate health, social care and community services.

The post holder will coordinate activity across practices and partner organisations, maintain accurate records, support multidisciplinary working and contribute to service improvement and the reduction of health inequalities. They will work within agreed protocols and their level of competence. The role is nonclinical and does not replace clinical assessment, diagnosis or treatment.

Improve coordination and communication between patients, carers, practices, PCN teams and partner services.

Help patients and carers understand, access and navigate appropriate health, social care and community support.

Support timely appointments, referrals, follow-up and delivery of agreed actions.

Provide efficient administrative support that enables PCN services to operate effectively.

Support delivery of contractual, quality and service-improvement priorities across the PCN.

Use accurate records, feedback and service information to help identify gaps and improve patient experience.

Provide reception and administrative support, including answering telephone enquiries, contacting patients, booking appointments and issuing questionnaires or surveys.

Support the triage and coordination of referrals to the Social Prescribing team and other appropriate services, ensuring agreed follow-up actions are completed.

Coordinate appointments, referrals and communication across primary care, community health, mental health, social care, advocacy and voluntary sector services.

Work closely with Care Coordinators, GP Assistants and other PCN colleagues, providing cover during periods of absence or increased workload.

Support the delivery and monitoring of QOF, IIF, incentive schemes, enhanced services and other PCN projects or initiatives.

Maintain accurate information and support data-quality improvements relating to PCN contracts, services and local priorities.

Contribute to patient communications, awareness campaigns and engagement activity across the PCN population.

Partnership working and service development

Develop effective working relationships with GP practices, PCN teams, community and social care services, carers organisations, advocacy services and voluntary sector partners.

Contribute to audits, service evaluations, quality-improvement work and the development of new pathways, projects and ways of working.

Identify and escalate gaps, duplication, access barriers and health inequalities to the appropriate PCN lead.

Patients, carers, families and authorised representatives

PCN Clinical Director, Strategy and Transformation Manager, Operations Manager and Digital Facilitator

GPs, practice managers, nurses, healthcare assistants and administrative teams

Social prescribers, care coordinators, general practice assistants, pharmacists and other Additional Roles Reimbursement Scheme colleagues

Work within the limits of competence and seek advice from an appropriate clinician or manager whenever the situation falls outside the role.

Follow organisational procedures relating to consent, mental capacity, best-interest decisionmaking, information sharing and involvement of carers or representatives.

Do not make clinical decisions, provide diagnosis or treatment advice, or independently interpret clinical results.

Recognise and respond to safeguarding concerns involving adults or children, including concerns about neglect, abuse, coercion, carer stress or breakdown of care arrangements.

Use professional curiosity, record concerns clearly and escalate promptly in accordance with local policy.

Complete all organisational mandatory and statutory training required for the role.

Complete role-specific learning in accessible communication, reasonable adjustments, safeguarding, consent and mental capacity, equality and inclusion, and personalised care.

Undertake appropriate care coordination and personalised care training as agreed with the line manager.

Participate in induction, supervision, annual appraisal and the development of a personal development plan.

Keep knowledge of relevant local services, pathways and good practice up to date and share learning with colleagues.

Contribute to clinical governance, audit, risk management, incident learning and qualityimprovement activity within the scope of the role.

Maintain complete, accurate and timely records and meet agreed deadlines for reporting and followup.

Treat all information concerning patients, carers, staff and the organisation as confidential and comply with organisational information-governance policies.

Process personal data fairly, lawfully and only for authorised purposes, in accordance with the Data Protection Act 2018, UK GDPR and relevant organisational procedures.

Share information only where there is a lawful basis, a legitimate need and appropriate authorisation, seeking advice when uncertain.

Follow health and safety, infection prevention and control, lone-working, incident-reporting and riskmanagement procedures.

Take reasonable care of personal safety and the safety of patients, carers, colleagues and visitors.

Promote equality, dignity, respect and inclusion and challenge barriers that may disadvantage patients, carers or communities.

Make reasonable adjustments to communication and service access and support culturally sensitive, trauma-informed and person-centred practice.

Work across PCN practices and other local venues as required; occasional home or community visits may be required subject to role protocols and risk assessment.

This job description is intended as a guide to the principal duties and responsibilities of the role and is not exhaustive. Duties may be reviewed and amended in consultation with the post holder to reflect changing organisational, contractual and service needs, provided they remain appropriate to the grade and scope of the post.

Person Specification

Knowledge and Skill

Essential

• Knowledge
• Understanding of person-centred care, confidentiality, consent, safeguarding and professional boundaries.
• Understanding of information governance, UK GDPR and complete, accurate and timely record keeping.
• Awareness of equality, health inequalities, accessible communication and reasonable adjustments.
• Understanding of when and how to escalate risks, safeguarding concerns or matters outside the roles competence.
• Excellent verbal and written communication skills, including managing telephone enquiries and adapting communication to individual needs.
• Strong organisation, prioritisation, time-management and follow-up skills.
• Ability to coordinate referrals, appointments, communication and agreed actions across several organisations.
• Ability to build trusting relationships while maintaining professional boundaries and handling sensitive conversations with empathy, patience and diplomacy.
• Ability to recognise risk or deterioration and escalate concerns appropriately.
• Ability to work independently within agreed protocols and contribute effectively to a team.
• Ability to collect, record, analyse and present information accurately and use it to identify gaps, duplication, access barriers and opportunities for service improvement.
• Ability to contribute to audits, reporting, patient communications and engagement activity.
• Proactive, flexible and solutions focused approach.

Desirable

• Knowledge of Primary Care Networks, QOF, IIF and enhanced services. Knowledge of local health, social care, community and voluntary sector services and referral pathways.
• Awareness of Social Prescribing and personalised care. Knowledge of mental capacity, best-interest decision-making and appropriate information sharing.
• Experience engaging people who are less likely to access services.

Experience

Essential

• Experience
• Experience of providing administrative or customer-facing support, including managing telephone enquiries and booking appointments.
• Experience of working within a multidisciplinary or multi-agency environment and liaising with different services.
• Experience of coordinating activity, following up referrals or agreed actions and maintaining accurate records.
• Experience of supporting people who may be vulnerable or experience barriers to accessing services.
• Experience of handling confidential or sensitive information.

Desirable

• Experience in primary care or the NHS.
• Experience of referral triage, Social Prescribing, call and recall, caseload administration or care navigation.
• Experience in patient engagement, surveys, awareness campaigns or service-user communications.
• Experience of audit, service evaluation, quality improvement or data-quality work.
• Experience of supporting QOF, IIF, enhanced services or similar performance frameworks.
• Experience using EMIS or another clinical record system.

Other Requirements

Essential

• Able to travel efficiently between PCN
• practices and other local venues.
• Able to work flexibly in response to service
• needs, within contracted hours.

Demonstration of PCN Values

Essential

• Commitment to patient-centred care, health
• equity, dignity and respect.
• Inclusive and non-judgemental approach.
• Reliable, accountable and able to maintain
• confidentiality.
• Commitment to collaborative working and
• continuous improvement.

Qualifications

Essential

• Good standard of general education,
• including English and mathematics at GCSE
• grade C/4 or equivalent.
• Competent in Microsoft Outlook, Word and
• Excel and confident using digital systems.
• Willingness to complete mandatory and role
• specific training.

Desirable

• Care coordination or personalised care
• training recognised by the Personalised
• Care Institute.

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

Havering Health Ltd

Address

St Georges Health And Wellbeing Hub

113 Suttons Lane

Hornchurch

Essex

RM12 6RR

United Kingdom

Employer's website

http://haveringhealth.co.uk/ (Opens in a new tab)

Job description

Job responsibilities

We do not provide visa sponsorship

JOB SUMMARY

Job summary The PCN Care Coordinator will provide proactive, person-centred coordination and practical support for people with learning disabilities and for unpaid carers registered with Havering Liberty PCN practices. The post holder will work across the Primary Care Network to improve identification, access, communication, continuity and follow-up, helping patients and carers navigate health, social care and community services. The role will support practices to deliver high-quality annual health checks and health action plans for people with learning disabilities, promote reasonable adjustments and accessible communication, and strengthen the identification and support of unpaid carers. The post holder will coordinate activity across practices and partner organisations, maintain accurate records, support multidisciplinary working and contribute to service improvement and reduction of health inequalities. The post holder will work within agreed protocols and their level of competence. The role is non-clinical and does not replace clinical assessment, diagnosis or treatment. Key aims of the role Improve the identification and recording of people with learning disabilities and unpaid carers across PCN practices. Increase equitable access to timely, person-centred primary care, including annual health checks, health action plans and relevant preventative care. Help patients and carers understand, access and navigate appropriate health, social care, advocacy and voluntary sector support. Promote reasonable adjustments, accessible information and communication tailored to individual needs. Coordinate follow-up and agreed actions so that patients and carers experience joined-up support. Use data, patient and carer feedback and quality-improvement methods to identify gaps and improve services. Key duties and responsibilities 1. Support for people with learning disabilities Work with practices to identify patients on the learning disability register and support the validation and maintenance of accurate records in EMIS. Coordinate call and recall activity for annual health checks, using accessible and personalised methods of contact and following up non-response in line with agreed protocols. Support appointment booking, including longer appointments, appropriate timing, carer involvement, interpreter or communication support and other reasonable adjustments where required. Contact patients, families, carers or representatives, where appropriately authorised, to explain the purpose of annual health checks and help address practical barriers to attendance. Support practices to prepare for annual health checks by ensuring relevant information, templates and previous actions are available to the clinical team. After clinical review, help coordinate non-clinical actions arising from health action plans, referrals, screening, immunisation, medication reviews or wider wellbeing needs, as directed by an appropriate clinician. Maintain and communicate agreed reasonable-adjustment information so that patients do not have to repeat their needs unnecessarily, while respecting consent and confidentiality. Promote accessible information, including easy-read materials, and check understanding using clear, respectful communication. Escalate clinical, safeguarding, capacity, consent or welfare concerns promptly to the appropriate clinician or safeguarding lead. 2. Support for unpaid carers Work with practices and PCN colleagues to improve the proactive identification and accurate recording of unpaid carers, including young adult carers where appropriate. Support carers to access health checks, vaccinations, wellbeing support, social prescribing, contingency planning and other locally available services, in line with current pathways. Recognise that a person may be both a patient and an unpaid carer and ensure their own health and wellbeing needs are not overlooked. Support appropriate involvement of carers in a patients care while respecting the patients consent, capacity, privacy and right to confidentiality. Identify indicators of carer strain, isolation or breakdown of caring arrangements and escalate concerns through agreed practice and safeguarding processes. Maintain up-to-date information about local carers services and build effective working relationships with relevant organisation. 3. Care coordination and personalised support Act as a consistent, accessible point of contact for allocated patients and carers, within agreed role boundaries. Listen to what matters to the person, identify practical barriers and support agreed personalised care and support planning. Coordinate referrals, appointments and follow-up actions across primary care, community health, mental health, social care, advocacy and voluntary sector services. Support transitions between services and life stages where coordinated primary care input is required. Arrange and support multidisciplinary or multi-agency discussions, prepare information, record agreed actions and track completion. Encourage use of appropriate digital services while providing alternatives for people who are digitally excluded or need additional support. Provide information and signposting in an impartial way and support informed choice. 4. Practice and PCN administration Prepare reports, dashboards and updates for practices and the PCN, ensuring that information is accurate, proportionate and appropriately anonymised or aggregated. Support meetings through agenda preparation, coordination, minute taking and action tracking. Contribute to PCN communications, awareness campaigns and engagement activity relating to learning disabilities and unpaid carers. Support data-quality improvement related to PCN contracts, enhanced services and local priorities. 5. Partnership working and service development Build constructive working relationships with GP practice teams, PCN colleagues, community services, adult social care, carers organisations, advocacy services and voluntary and community sector partners. Help map referral routes and maintain an accurate directory of relevant local services. Seek and use patient and carer feedback to improve accessibility, experience and outcomes. Contribute to audits, quality-improvement activity, service evaluation and the development of new pathways or projects. Identify gaps, duplication, access barriers and health inequalities and raise these with the appropriate PCN lead. Work flexibly across PCN sites and provide reasonable cross-cover for other non-clinical PCN functions where compatible with the role. Collaborative working relationships People with learning disabilities, unpaid carers, families and authorised representatives PCN Clinical Director, Strategy and Transformation Manager, Operations Manager and Digital Facilitator GPs, practice managers, nurses, healthcare assistants and administrative teams Social prescribers, care coordinators, pharmacists and other Additional Roles Reimbursement Scheme colleagues Community learning disability services, mental health services, social care, advocacy and safeguarding teams Local carers organisations, voluntary and community sector services and neighbourhood partners Professional boundaries, consent and safeguarding Work within the limits of competence and seek advice from an appropriate clinician or manager whenever the situation falls outside the role. Follow organisational procedures relating to consent, mental capacity, best-interest decision-making, information sharing and involvement of carers or representatives. Do not make clinical decisions, provide diagnosis or treatment advice, or independently interpret clinical results. Recognise and respond to safeguarding concerns involving adults or children, including concerns about neglect, abuse, coercion, carer stress or breakdown of care arrangements. Use professional curiosity, record concerns clearly and escalate promptly in accordance with local policy. Education, learning and development Complete all organisational mandatory and statutory training required for the role. Complete role-specific learning in learning disability awareness, accessible communication, reasonable adjustments, autism awareness, safeguarding, consent and mental capacity, unpaid carer awareness and personalised care. Participate in induction, supervision, annual appraisal and the development of a personal development plan. Keep knowledge of relevant local services, pathways and good practice up to date and share learning with colleagues. Quality, information governance and confidentiality Contribute to clinical governance, audit, risk management, incident learning and quality-improvement activity within the scope of the role. Maintain complete, accurate and timely records and meet agreed deadlines for reporting and follow-up. Treat all information as confidential and comply with organisational information-governance policies. Process personal data fairly, lawfully and only for authorised purposes, in accordance with the Data Protection Act 2018, UK GDPR and relevant organisational procedures. Share information only where there is a lawful basis, a legitimate need and appropriate authorisation. Health, safety, equality and inclusion Follow health and safety, infection prevention and control, lone-working, incident-reporting and risk-management procedures. Take reasonable care of personal safety and the safety of patients, carers, colleagues and visitors.

Person Specification

Knowledge and Skill

Essential

• Understanding of person-centred care,
• confidentiality, consent, safeguarding and
• professional boundaries.
• Awareness of health inequalities and
• common barriers experienced by people with
• learning disabilities and unpaid carers.
• Understanding of the importance of
• reasonable adjustments and accessible
• communication.
• Excellent verbal and written communication
• skills, with the ability to adapt
• communication to individual needs.
• Strong organisation, prioritisation, time
• management and follow-up skills.
• Ability to build trusting relationships while
• maintaining professional boundaries.
• Ability to handle sensitive conversations with
• empathy, patience and diplomacy.
• Ability to recognise risk or deterioration and
• escalate concerns appropriately.
• Ability to work independently within agreed
• protocols and contribute effectively to a
• team.
• Ability to collect, record and present
• information accurately.
• Proactive, flexible and solutions-focused
• approach.

Desirable

• Knowledge of annual health checks and
• health action plans for people with
• learning disabilities.
• Knowledge of local learning disability,
• carers, social care, advocacy and
• voluntary sector services.
• Awareness of mental capacity
• principles and information-sharing
• considerations.
• Experience producing accessible or
• easy-read information.
• Quality-improvement, audit or service
• evaluation skills.
• Experience engaging people who are
• less likely to access services.

Experience

Essential

• At least two years experience in health,
• social care, education, community services
• or another support role involving direct
• contact with people, families or carers, in a
• paid or voluntary capacity.
• Experience of working within a
• multidisciplinary or multi-agency
• environment.
• Experience of maintaining accurate records,
• coordinating activity and following up
• actions.
• Experience of supporting people who may be
• vulnerable or experience barriers to
• accessing services.

Desirable

• Experience in primary care or the NHS.
• Experience supporting people with
• learning disabilities and/or unpaid
• carers.
• Experience of call and recall, caseload
• administration or care navigation.
• Experience using EMIS or another
• clinical record system.

Other Requirements

Essential

• Able to travel efficiently between PCN
• practices and other local venues.
• Able to work flexibly in response to service
• needs, within contracted hours.

Desirable

• Ability to undertake occasional
• community or home visits in
• accordance with policy and risk
• assessment.

Demonstration of PCN Values

Essential

• Commitment to patient-centred care, health
• equity, dignity and respect.
• Inclusive and non-judgemental approach.
• Reliable, accountable and able to maintain
• confidentiality.
• Commitment to collaborative working and
• continuous improvement.

Qualifications

Essential

• Good standard of general education,
• including English and mathematics at GCSE
• grade C/4 or equivalent.
• Competent in Microsoft Outlook, Word and
• Excel and confident using digital systems.
• Willingness to complete mandatory and role
• specific training.

Desirable

• Care coordination or personalised care
• training recognised by the Personalised
• Care Institute.
• Training in learning disability
• awareness, autism, accessible
• communication, mental capacity or
• unpaid carer support.

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

Havering Health Ltd

Address

Hornchurch Healthcare

Romford

Essex

RM11 1AX

United Kingdom

Employer's website

http://haveringhealth.co.uk/ (Opens in a new tab)