Job summary
We are looking to recruit to the post of Care Co-ordinator to work within our Primary Care Network Multi-disciplinary Team (MDT).
The successful candidate will play a key role in proactively identifying and working with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
Main duties of the job
The post holder will work closely with GPs, Nurse Practitioners and other MDT members, making sure that appropriate support is made available to people; supporting them to understand and manage their condition, ensuring their changing needs are addressed, and enable people to navigate through the health and care system.
They will enable people to access the services and support they require to meet their health and wellbeing needs, helping to improve people’s quality of life.
The post holder will work with a diverse range of people from different cultural and social backgrounds. The ability to work confidently and effectively in a varied, and sometimes challenging environment is essential.
The successful candidate will have excellent interpersonal and communication skills, and be organised, patient and empathetic. They will have experience of working in health, social care or other support roles including direct contact with people, families or carers.
About us
This is an exciting time to join the Kettering South and Rural PCN. We are an innovative and forward thinking Primary Care Network with a strong reputation for Quality Improvement and investing in people.
Our PCN spans 3 member Practices (Burton Latimer MC, Mawsley MC and Dryland Surgery) embracing a patient list of just over 30,000 patients. We are seeking an enthusiastic, patient-focused, highly and independently motivated Care Co-Ordinator to join and work across our PCN member practices.
We are committed to improving the care provided to patients, reducing health inequalities and raising the quality and standards of GP practice.
Job description
Job responsibilities
·
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 to manage their needs
and achieve better healthcare outcomes.
·
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 understand their level of
knowledge, skills and confidence (their “Activation” level) when engaging with
their health and wellbeing, including through the use of the Patient Activation
Measure (PAM).
·
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.
·
Support people to take up training and
employment, and to access appropriate benefits where eligible.
·
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; helping to ensure patients receive a joined up service and the
most appropriate support.
·
Work collaboratively with GPs and other primary
care professionals within the PCN to proactively identify and manage a
caseload, which may include patients with long-term health conditions, and
where appropriate, refer back to other health professionals within the PCN.
·
Support the coordination and delivery of
multidisciplinary teams with the PCN.
·
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.
·
Explore and assist people to access a personal
health budget where appropriate.
·
Work with people, their families, carers and
healthcare team members to encourage effective help-seeking behaviours.
Job description
Job responsibilities
·
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 to manage their needs
and achieve better healthcare outcomes.
·
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 understand their level of
knowledge, skills and confidence (their “Activation” level) when engaging with
their health and wellbeing, including through the use of the Patient Activation
Measure (PAM).
·
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.
·
Support people to take up training and
employment, and to access appropriate benefits where eligible.
·
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; helping to ensure patients receive a joined up service and the
most appropriate support.
·
Work collaboratively with GPs and other primary
care professionals within the PCN to proactively identify and manage a
caseload, which may include patients with long-term health conditions, and
where appropriate, refer back to other health professionals within the PCN.
·
Support the coordination and delivery of
multidisciplinary teams with the PCN.
·
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.
·
Explore and assist people to access a personal
health budget where appropriate.
·
Work with people, their families, carers and
healthcare team members to encourage effective help-seeking behaviours.
Person Specification
Other
Essential
- Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
- Willingness to work flexible hours when required to meet work demands
- Access to own transport and ability to travel across the locality on a regular basis, including visiting people in their own homes.
Qualifications
Essential
- Ideally, Level 2 diploma in health and social care or equivalent qualification.
- Demonstrable commitment to professional and personal development.
Experience
Essential
- 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 of supporting people, their families and carers in a related role (including unpaid work).
- Experience of working within multi-professional team environments.
- Experience of data collection and using tools to assess the impact of services.
- Experiences of partnership/collaborative working and of building relationships across a variety of organisations.
- Knowledge of the personalised care approach.
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Good organisational skills, including planning, prioritising, time management and record keeping.
- Ability to recognise and work within limits of competence and seek advice when needed.
- Basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social.
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence.
- Understanding of, and commitment to, equality, diversity, and inclusion.
- Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook.
- Ability and preparedness to learn PCN specific electronic database and record keeping systems.
Desirable
- Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement.
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
- Experience or training in personalised care and support planning.
- Knowledge of how the NHS works, including Primary Care and PCNs.
- Knowledge of Safeguarding Children and Vulnerable Adults policies and procedures.
Personal Qualities and Attributes
Essential
- Ability to listen, empathise with people and provide person centred support in a non-judgemental way.
- Ability to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Commitment to reducing health inequalities and proactively working to reach people from all communities.
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- 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 that person needs is beyond the scope of the link worker 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.
Person Specification
Other
Essential
- Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
- Willingness to work flexible hours when required to meet work demands
- Access to own transport and ability to travel across the locality on a regular basis, including visiting people in their own homes.
Qualifications
Essential
- Ideally, Level 2 diploma in health and social care or equivalent qualification.
- Demonstrable commitment to professional and personal development.
Experience
Essential
- 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 of supporting people, their families and carers in a related role (including unpaid work).
- Experience of working within multi-professional team environments.
- Experience of data collection and using tools to assess the impact of services.
- Experiences of partnership/collaborative working and of building relationships across a variety of organisations.
- Knowledge of the personalised care approach.
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Good organisational skills, including planning, prioritising, time management and record keeping.
- Ability to recognise and work within limits of competence and seek advice when needed.
- Basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social.
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence.
- Understanding of, and commitment to, equality, diversity, and inclusion.
- Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook.
- Ability and preparedness to learn PCN specific electronic database and record keeping systems.
Desirable
- Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement.
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
- Experience or training in personalised care and support planning.
- Knowledge of how the NHS works, including Primary Care and PCNs.
- Knowledge of Safeguarding Children and Vulnerable Adults policies and procedures.
Personal Qualities and Attributes
Essential
- Ability to listen, empathise with people and provide person centred support in a non-judgemental way.
- Ability to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Commitment to reducing health inequalities and proactively working to reach people from all communities.
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- 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 that person needs is beyond the scope of the link worker 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.
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.