Care Coordinator

Job description

Job responsibilities

Responsible to: Clinical Director

Accountable to: PCN Clinical Director

Salary: £21,892-£24,157

Job Summary

The Care Coordinator will be part of the Primary Care Network (PCN) Multi-Disciplinary Team (MDT) who will be responsible for managing the care of people registered with practices within Townships 1 & 2 PCN. This will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population.

The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions. An ethos of promotion of independence and partnership-working is integral to this post.

A key part of the role of a care coordinator role is in the care Homes MDT: improving the continuity of care by acting as a point of contact for residents, families and professionals who visit care homes, such as MDT members and in-reach specialists.

They will support the MDT with the weekly virtual home round through identification of people in need of review, or collation of information on people requiring an MDT review in addition to providing coordination, secretarial and administrative support to the MDTs within a single or multiple PCNs.

Primary Duties and Areas of Responsibility

Multi-Disciplinary Teams

Overall responsibility for arranging the weekly PCN led MDT meetings (including the weekly virtual Care Home(s) MDT) and the smooth running of integrated care within the team setting. The key role of the Care Coordinator will be to schedule the weekly MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.

Coordinate and manage the administrative functions of MDT meetings.

Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.

Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.

Manage reporting required and associated within the DES specifications for required services.

Patient Identification

Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.

Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the weekly MDT meetings.

Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT.

Signpost team members, service users and carers to relevant services

Maintenance of IT based information systems and responsibility for key performance data:

To ensure the IT requirements for recording activity are adhered to in collaboration with other team members

Accurate update and maintenance of GP systems within the MDT.

To provide agreed performance/activity data within the MDT and PCN

Communication and collaborative working relationships

Demonstrates ability to work as a member of a team.

Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary.

Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.

Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations.

Work with service users, PCN practices and partners e.g. Care Homes to ensure new referrals are logged and allocated

Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT

Acting as a point of contact for residents, families and professionals who visit the care home, such as MDT members and in-reach specialists.

Meet regularly with the clinical lead and review case load and MDT function.

Provide background information about individuals for the weekly MDT meetings

Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public

Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT

Other responsibilities

To act at all times in an anti-discriminatory manner

To be able to plan and respond to workload according to operational priorities

To support the delivery of these functions across wider locality areas where necessary

To undertake any training required in order to maintain competency including mandatory training

To contribute to, and work within a safe working environment.

The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures

The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required

The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.

Patient Care

Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding

Effectively use all methods of communication and be aware of and manage barriers to communication

Effectively recognise and manage challenging behaviours, carers and or relatives

Provide information to patients, their carers and/or relatives on behalf of the team

Supporting Care Delivery

Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated

Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.

Follow through with service users and others involved to ensure all services and care arrangements are in place

Autonomy/Scope within Role

The post holder will be required to work within clearly defined organisational protocols, policies and procedures

Key Relationships

Key Working Relationships Internal:

Clinical Lead for the MDT

GPs and General practice teams within the PCN

PCN Clinical Director

MDT members including but not exhaustive: Clinical Pharmacists, technicians, Physician Associates, Physios, Paramedics, Social Prescribing Link Workers,

Key Working Relationships External:

GPs from neighbouring PCNs

Service providers

Social care

Voluntary services

Patients/service users

Carers/relatives

Health and Safety/Risk Management

The post-holder must comply at all times with the organisation and Practices Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System.

The post-holder will comply with the Data Protection Act (1984), The General Data Protection Regulations (2018) and the Access to Health Records Act (1990).

Equality and Diversity

The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc.

Respect for Patient Confidentiality

The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.

Special Working Conditions

The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies.

Person Specification

Qualifications

Essential

• A minimum of 2 years experience of the healthcare setting and or social care setting or multi-disciplinary setting
• NVQ level 3 or equivalent experience

Experience

Essential

• Experience of working in a busy and demanding environment
• Experience in using Microsoft office packages
• Experience of collating data and information

Desirable

• Experience in using clinical systems
• Experience of care of the elderly

Knowledge and Understanding

Essential

• An understanding and knowledge of the workings of the NHS and the challenges it faces
• Knowledge/familiarity of medical terminology

Skills, Competancies and Attributes

Essential

• Computer literate with an ability to use the required systems/office packages
• Excellent negotiation skills
• Excellent communication skills, verbal and written, with the ability to adjust their communication style and content to suit the audience
• Can demonstrate ability to work under own initiative and as part of a team
• Able to meet deadlines, work under pressure and balance priorities
• Able to build and sustain relationships at all levels, actively involving stakeholders where appropriate
• Committed to personal development
• Approachable and flexible
• Honest and reliable
• Sensitive to patients needs
• As the role requires working at a variety of sites you will have to the ability to travel

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

Hackenthorpe Medical Centre

Address

2 Goathland Place

Sheffield

S13 7TE

Employer's website

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