Care Coordinator (WW PCN)

Job description

Job responsibilities

The post will evolve as we develop our services but you will be required to undertake the following duties:

• Cancer care reviews
• Dementia reviews
• LD reviews
• Organise and run one stop shops
• Frailty reviews
• Carer support
• Increasing cancer screening uptake
• Prevent inappropriate admissions, and support people to have an effective discharge from services
• You will help tackle inequalities in health and social care. An ethos of promotion of independence and partnership-working is integral to this post.
• Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans
• 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.

Signposting to other services to maintain their independence and improve their health and well being

• Work collaboratively with colleagues to improve outcomes for patients.

Develop and maintain a detailed knowledge of local community and voluntary sector services to enable supported sign-posting of people with an identified need

Liaise with primary, secondary and specialist care services as required

Work with the multi-disciplinary team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support

Visit patients in the community, home or care home settings to assess and discuss their care needs involving carers as appropriate

Implement personal care plans for individual patients, ensuring preventative actions are detailed to support the appropriate use of services

Communicate the care plan to the GP and any other professionals involved in the persons care and upload it to the relevant records

Ensure that identified patients receive the right level of help at the right time and help them to experience a joined-up service by liaising with relevant service providers

Work with patients, carers and healthcare team members to encourage the patient to adopt effective self-management and self-help seeking approaches to reduce unnecessary hospital admissions

Support patients to access community care assessments as well as carers assessments

Where a personal healthcare budget is allocated provide advice as required regarding the key choices the patient will need to make.

Identify unpaid carers and direct them to access services as appropriate to provide them with support.

Identify when urgent action or a step up in care is required and promptly alert the relevant professionals involved, highlighting any safety concerns. Undertake training to be a carers champion and offer more in-depth support.

Follow up on communications from out of hospital and in-patient services regarding changes in the condition of patients to support the practice to respond proactively to potentially unmet needs

Participate in Practice multi-disciplinary meetings to discuss Practice patients actively being managed by other teams and any other patients from the Practices caseload needing discussion.

Maintain accurate and up-to-date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e. entering notes onto SystmOne using agreed read codes.

To run regular patient searches using SystmOne in order to have an up-to-date record of the progress of achievement of Key Performance Indicators.

To work closely with the practice and PCN healthcare roles, the CC is to identify and work with a cohort of people to support their personalised care requirements, (as the role develops)

To collate all of a patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice

To assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools

To liaise with other CCs in other practices within the PCN and share best practice

To provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW) and Health and Wellbeing Coaches

To support the delivery of enhanced services and other service requirements on behalf of the PCN

To undertake all mandatory training and induction programmes

To contribute to and embrace the spectrum of clinical governance

To attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed.

To maintain a clean, tidy, effective working area at all times

Supporting patients and care homes to increase use of digital technology.

Please see the attached supporting document for a full job description/person specification for this role.

Key Tasks

Enable access to personalised care and support

Take referrals for individuals or proactively identify people who could benefit from support through care coordination;

Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs;

Support people to develop and implement personalised care and support plans;

Review and update personalised care and support plans at regular intervals;

Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes;

Where a personal health budget is an option, to work with the person and the local CCG team to provide advice and support as appropriate.

Coordinate and integrate care

• Help people transition seamlessly between services and support them to navigate through the health and care system;
• Refer onwards to social prescribing link workers and health and wellbeing coaches, and other services, where required;
• Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;
• Actively participate in multidisciplinary team meetings in the PCN as and when appropriate;
• Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
• Keep accurate and up-to-date records of contacts, appropriately using GP and other

records systems relevant to the role, adhering to information governance and data protection legislation;

• Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing;
• Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives;
• Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.

Professional development

Work with a named clinical point of contact for advice and support.

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.

3. 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;

Act as a champion for personalised care and shared decision making within the PCN;

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;

Work in accordance with the practices and PCNs policies and procedures;

Contribute to the wider aims and objectives of the PCN to improve and support primary care.

Duties may vary from time to time without changing the general character of the post or the level of responsibility. Other duties may be required to meet the responsibilities of the post and the requirements of the organisation. The organisation also supports multiple events throughout the year, you may be required to attend these should they need on-the-day support.

Person Specification

Qualifications

Essential

• Educated to GCSE Level or Equivalent

Experience

Essential

• Experience of dealing with vulnerable patients
• Evidence of ability to work autonomously.
• Evidence of working within a multidisciplinary team
• Experience of working in a healthcare setting

Desirable

• Experience of using SystmOne
• Experience in primary care
• Experience of community and care home settings
• Experience of dealing with patients with long term conditions.
• Experience of facilitating group work.
• Project planning

Skills & Knowledge

Essential

• Excellent communication skills. Listening, written and verbal
• Access to own transport and ability to travel across the locality as required, including to visit people in their own homes
• Ability to deal with complex facts/situations, requiring analysis, interpretation and comparison of a range of options.
• Clear, polite telephone manner

Desirable

• Good IT skills
• Working knowledge of Microsoft Office packages

Aptitude

Essential

• Ability to effectively organise own workload and that of others with minimum supervision
• Ability to achieve goals with deadlines.
• Ability to work autonomously as well as within a team
• Ability to make decisions under pressure
• Ability to work sensitively to maintain high levels of diplomacy and confidentiality
• Enthusiasm, drive and the ability to cope in challenging situations

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

Conexus Healthcare CIC

Address

Lupset Health Centre

George-a-green Court

Wakefield

West Yorkshire

WF28FE

Employer's website

https://conexus-healthcare.org/ (Opens in a new tab)