West Mendip Primary Care Network Care Co-ordinator

Job description

Job responsibilities

1. ENABLE ACCESS TO PERSONALISED CARE AND SUPPORT

Take referrals or proactively identify people who could benefit from support through care co-ordination.

Have a positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.

Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance.

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.

Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.

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.

2. CO-ORDINATE ANDINTEGRATE CARE

Help people transition seamlessly between secondary and community care services, supporting people to navigate through the wider health and care system.

Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.

Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a co-ordinated 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.

Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.

Record what interventions are used to support people, and how people are developing on their health and care journey.

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 co-ordination 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.

3. SUPERVISION/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.

Access relevant GPs to discuss patient related concerns, and be supported to follow appropriate safeguarding procedures.

4. MISCELLANEOUS

Establish strong working relationships with GPs and practice teams and work collaboratively with other care co-ordinators, 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.

Person Specification

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 working within multi-professional
• team environments
• Experience of supporting people, their
• families and carers in a related role

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 data collection and using
• tools to measure the impact of services
• Experience of working with elderly
• or vulnerable people, complying with
• best practice and relevant legislation

Qualifications

Essential

• 5 GCSEs or equivalent, to include English and Maths: A*- C or 9 - 4
• grade

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

Vine Surgery Partnership

Address

West Mendip Primary Care Network

Hindhayes Lane

Street

Somerset

BA16 0ET

Employer's website

https://www.vinesurgery.nhs.uk/ (Opens in a new tab)