Job summary
The successful candidate would be working for Central Middlesbrough Primary Care Network (PCN) which include the following member practices : Discovery Practice, Endeavour Practice, Martonside Medical Centre, Park Surgery, Erimus Practice, Prospect Surgery and Thorntree Surgery.
In this role you would be supporting the PCN member practices and their registered patient population.
Care coordinators play an important role
within a Primary Care Network (PCN) to proactively identify and work with
people, including the frail/elderly and those with long-term conditions, to
provide coordination and navigation of care and support across health and Social care
services.
They work closely with GPs and practice
teams to manage specified cohorts of patients, acting as a central point of contact to
ensure appropriate support is made available to them and their carers;
supporting them to understand and manage their condition and ensuring their
changing needs are addressed. This will include gathering information from patients to support development of Personalised Care Planning and for Referral.
Our Care Co-Ordinator will also be part of a growing team of additional roles within the PCN which includes roles such as Pharmacist team, Social Prescribers and Physiotherapy and assist and support ways of integrated working across organisations and delivering on PCN service contracts.
Main duties of the job
Care Co-Ordinators support practices to develop and gather information
for health and social care needs. Ensuring
relevant information is recorded accurately in patient health records to
support patient personalised care plan development. The post holder will assist
practices to evaluate specific cohorts of patients and engage people to participate in order to reduce health inequalities.
This is achieved by bringing together
all the information about a persons identified care and support needs and
exploring options to meet these within a single personalised care and support
plan, based on what matters to the person. Care coordinators, review patients
needs and help them access the services and support they require to understand
and manage their own health and wellbeing, referring to social prescribing link
workers, health and wellbeing coaches, and other professionals where
appropriate.
Care coordinators could potentially
provide time, capacity and expertise to support people in preparing for or
following-up clinical conversations they have with primary care professionals
to enable them to be actively involved in managing their care and supported to
make choices that are right for them. Their aim is to help people improve their
quality of life.
About us
Central Middlesbrough Primary Care Network is a developing PCN which has 7 member practices which are Discovery Practice, Endeavour Practice, Martonside Medical Centre, Park Surgery, Erimus Practice, Prospect Surgery and Thorntree Surgery. We serve a collective population of approximately 52000 people.
As well as our individual practice teams we have our PCN additional roles team of which includes our Care Co-Ordinators. These roles are expanding with the recent introduction of an Advanced Nurse Practitioner providing Enhanced Health in our PCN aligned Care Homes. Other roles are Physiotherapists, Social Prescribers, Pharmacists and Pharmacy Technicians, Mental Health Practitioner, Mental Health and Wellbeing coach and a Digital and Transformation Lead.
Through the development of the PCN our member practices and the PCN teams have fostered good working relationships and aided improved working across our organisations. Our PCN alliance has help to improve the sustainability and resilience of our general practices. We are now able to support our practices and share best practice and learning in a more natural way. In particular our PCN staff help with this engagement moving from practice to practice this has fostered good working relationships across our PCN practice teams.
Job description
Job responsibilities
Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.
Care coordinators must be caring, dedicated, reliable and person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.
You will work closely with the GPs and other primary care professionals within the PCN to manage a caseload of patients identified as having an unmet health need, making sure that appropriate support is made available to them and their carers (if applicable), and ensuring that their changing needs are addressed. This could mean undertaking assessments for referral to primary or social care services and/or organising MDT discussions between the appropriate professionals to discuss the patients care needs. This will mean for specific areas of your role you may be aligned to dedicated practice(s) within the PCN to target their registered population or at times to support care for a specified cohort of registered patients you will be required to work across the whole PCN's member practices.
You will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions, an unmet health need or a cohort of patients who historically dont engage with primary care services. An ethos of promotion of independence, shared decision making, personalisation and partnership-working is integral to this post. As the role evolves the care coordinatorwill undertake direct work with these cohorts and families to develop personalised care plans.
Care coordinator role also support the COVID vaccination clinics and designated site running. Providing support to teams administering care home and house bound patient vaccinations as well as supporting clinics at the COVID Vaccination Hub or in practices for the PCN.
Please note that the role of a care coordinator is not a clinical role.
Key responsibilities
Care Coordinators will:
- Take overall responsibility for arranging the weekly care home rounds and the smooth running of the administrative processes for practice and care homes adding appropriate patients to be seen on these rounds.
- Schedule MDT meetings as required, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
- Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
- Support the development and continuous review of Personalised Care & Support plans for all PCN aligned care home residents who are registered to practices within the PCN.
- Provide coordination and navigation for people and their carers across health and care services, referring to social prescribing link workers, health and wellbeing coaches, and other primary care professionals when appropriate
- Work with the PCN multi-disciplinary team to utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
- Support PCN staff and patients to be prepared to have shared-decision making conversations, including utilising decision aids and tools.
- Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
- 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.
- Supporting the COVID vaccination programmes by supporting the delivery of vaccinations in care homes, to housebound patients and any other eligible cohorts.
- Ensuring cool bags and vaccinations trolleys are prepared correctly and in a timely fashion.
- Recording the delivery and handing out of vaccine vials as per the PCN processes
- Monitoring and regulating the temperature of the fridge the COVID vaccine is stored in.
Referrals
- As part of the PCN multi-disciplinary team, build relationships with staff in GP practices within the PCN, attending relevant MDT meetings, providing information and feedback on care coordination priorities.
- Supporting patients to book primary care appointments for reviews and healthchecks to support proactive care approaches.
- Liaise directly with Care Homes and other key providers, to identify patients for discussion at MDT, and compile and circulate relevant information to attendees.
- Actively refer patients to Primary, Social Care Services and PCN ARRS roles where appropriate to do so.
Provide personalised support
Work with the person, their families and carers and consider how they can all be supported by services available to them.
Bring together a persons identified care needs and explore their options to meet these within a simple coproduced personalise care and support plan, including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
Seek advice and support from the GP supervisor and/or identified individual(s) to discuss patient-related concerns (e.g. abuse, domestic violence and support with mental health), referring the patient back to the GP or other suitable health professional if required.
Data capture
- Work sensitively with people, their families and carers to capture key information, enabling comprehensive and accurate records of support.
- Encourage people, their families and carers to provide feedback and engage fully in the care coordination process.
- Work closely within the MDT and with GP practices within the PCN to ensure that the comprehensive records of MDT case discussions are inputted into clinical systems, adhering to data protection legislation and data sharing agreements.
Other
- Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
- Contribute to the development of policies and plans relating to equality, diversity and health inequalities.
- Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
NB: This job description outlines the key duties that are expected of you within the role although is not an exhaustive list. It may be amended in line with experience, business requirements and as a result of any future organisational change.
Job description
Job responsibilities
Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.
Care coordinators must be caring, dedicated, reliable and person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.
You will work closely with the GPs and other primary care professionals within the PCN to manage a caseload of patients identified as having an unmet health need, making sure that appropriate support is made available to them and their carers (if applicable), and ensuring that their changing needs are addressed. This could mean undertaking assessments for referral to primary or social care services and/or organising MDT discussions between the appropriate professionals to discuss the patients care needs. This will mean for specific areas of your role you may be aligned to dedicated practice(s) within the PCN to target their registered population or at times to support care for a specified cohort of registered patients you will be required to work across the whole PCN's member practices.
You will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions, an unmet health need or a cohort of patients who historically dont engage with primary care services. An ethos of promotion of independence, shared decision making, personalisation and partnership-working is integral to this post. As the role evolves the care coordinatorwill undertake direct work with these cohorts and families to develop personalised care plans.
Care coordinator role also support the COVID vaccination clinics and designated site running. Providing support to teams administering care home and house bound patient vaccinations as well as supporting clinics at the COVID Vaccination Hub or in practices for the PCN.
Please note that the role of a care coordinator is not a clinical role.
Key responsibilities
Care Coordinators will:
- Take overall responsibility for arranging the weekly care home rounds and the smooth running of the administrative processes for practice and care homes adding appropriate patients to be seen on these rounds.
- Schedule MDT meetings as required, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
- Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
- Support the development and continuous review of Personalised Care & Support plans for all PCN aligned care home residents who are registered to practices within the PCN.
- Provide coordination and navigation for people and their carers across health and care services, referring to social prescribing link workers, health and wellbeing coaches, and other primary care professionals when appropriate
- Work with the PCN multi-disciplinary team to utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
- Support PCN staff and patients to be prepared to have shared-decision making conversations, including utilising decision aids and tools.
- Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
- 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.
- Supporting the COVID vaccination programmes by supporting the delivery of vaccinations in care homes, to housebound patients and any other eligible cohorts.
- Ensuring cool bags and vaccinations trolleys are prepared correctly and in a timely fashion.
- Recording the delivery and handing out of vaccine vials as per the PCN processes
- Monitoring and regulating the temperature of the fridge the COVID vaccine is stored in.
Referrals
- As part of the PCN multi-disciplinary team, build relationships with staff in GP practices within the PCN, attending relevant MDT meetings, providing information and feedback on care coordination priorities.
- Supporting patients to book primary care appointments for reviews and healthchecks to support proactive care approaches.
- Liaise directly with Care Homes and other key providers, to identify patients for discussion at MDT, and compile and circulate relevant information to attendees.
- Actively refer patients to Primary, Social Care Services and PCN ARRS roles where appropriate to do so.
Provide personalised support
Work with the person, their families and carers and consider how they can all be supported by services available to them.
Bring together a persons identified care needs and explore their options to meet these within a simple coproduced personalise care and support plan, including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
Seek advice and support from the GP supervisor and/or identified individual(s) to discuss patient-related concerns (e.g. abuse, domestic violence and support with mental health), referring the patient back to the GP or other suitable health professional if required.
Data capture
- Work sensitively with people, their families and carers to capture key information, enabling comprehensive and accurate records of support.
- Encourage people, their families and carers to provide feedback and engage fully in the care coordination process.
- Work closely within the MDT and with GP practices within the PCN to ensure that the comprehensive records of MDT case discussions are inputted into clinical systems, adhering to data protection legislation and data sharing agreements.
Other
- Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
- Contribute to the development of policies and plans relating to equality, diversity and health inequalities.
- Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
NB: This job description outlines the key duties that are expected of you within the role although is not an exhaustive list. It may be amended in line with experience, business requirements and as a result of any future organisational change.
Person Specification
Qualifications
Essential
- NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
- Demonstrable commitment to professional and personal development
- Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook
- Clinical systemone knowledge and advantage but not essential.
Desirable
- Clinical systemone knowledge and advantage but not essential.
Experience
Essential
- Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
- Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes (E)
- Experience providing advice/signposting to users (E)
- Able to collate and disseminate voluminous and sometimes complex information (E)
- Able to assess and work within an individuals level of health literacy and support them to increase their understanding (E)
- Proven record of excellent written and verbal communication skills (E)
- Excellent motivational and influencing skills
- Excellent interpersonal skills (E)
- Able to deal with service users sensitively (E)
- Able to work as part of a team (E)
- Able to prioritise and manage own workload (E)
- Ability to analyse and interpret information and present results in a clear and concise manner (E)
- Excellent organisational and administration skills (E)
Desirable
- Experience of working in a multi-disciplinary setting where influence and negotiation is required (D)
- Experience of undertaking quality improvement activity (D)
- Experience of using technology and digital tools to support health and wellbeing (D)
- Experience of coproduction with patients or service-users (D)
- Skills:
- Skilled in use of person-centred measurement & outcomes delivery (D)
- Able to use asset-based approaches when working with individuals and families (D)
- Able to use patient activation tools to measure knowledge, skills and confidence in managing their own health and wellbeing (D)
- Strong analytical and judgement skills(D)
- Knowledge and use of clinical records databased (systmone) and other digital innovations to support identification/recording/input and management of patient's clinical records and data collection. (D) *training can be given but employees must have good learning set skills of using similar digital systems.
Knowledge and Skills
Essential
- Knowledge:
- Level 2 qualification in Maths and English (M)
- Understanding of health and social care processes (E)
- Knowledge/familiarity with medical terminology (E)
- Understanding of social determinants of health and how these can be addressed with patients (E)
- High levels of health literacy (E)
- Excellent knowledge of Microsoft products and their use (E)
Desirable
- Knowledge:
- Educated to level 3 in a relevant topic, or working towards (D)
- Knowledge of a range of technology and digital tools that can be used support health and wellbeing (D)
- Understanding of current issues facing the NHS (D)
Vehicle Access
Essential
- As it will be necessary to travel between PCN practice(s) within Middlesbrough, aligned care homes and deliver support to patients within the local community. Therefore it is essential that our care coordinators have access to their own vehicle and hold a current valid divers license.
Person Specification
Qualifications
Essential
- NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
- Demonstrable commitment to professional and personal development
- Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook
- Clinical systemone knowledge and advantage but not essential.
Desirable
- Clinical systemone knowledge and advantage but not essential.
Experience
Essential
- Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
- Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes (E)
- Experience providing advice/signposting to users (E)
- Able to collate and disseminate voluminous and sometimes complex information (E)
- Able to assess and work within an individuals level of health literacy and support them to increase their understanding (E)
- Proven record of excellent written and verbal communication skills (E)
- Excellent motivational and influencing skills
- Excellent interpersonal skills (E)
- Able to deal with service users sensitively (E)
- Able to work as part of a team (E)
- Able to prioritise and manage own workload (E)
- Ability to analyse and interpret information and present results in a clear and concise manner (E)
- Excellent organisational and administration skills (E)
Desirable
- Experience of working in a multi-disciplinary setting where influence and negotiation is required (D)
- Experience of undertaking quality improvement activity (D)
- Experience of using technology and digital tools to support health and wellbeing (D)
- Experience of coproduction with patients or service-users (D)
- Skills:
- Skilled in use of person-centred measurement & outcomes delivery (D)
- Able to use asset-based approaches when working with individuals and families (D)
- Able to use patient activation tools to measure knowledge, skills and confidence in managing their own health and wellbeing (D)
- Strong analytical and judgement skills(D)
- Knowledge and use of clinical records databased (systmone) and other digital innovations to support identification/recording/input and management of patient's clinical records and data collection. (D) *training can be given but employees must have good learning set skills of using similar digital systems.
Knowledge and Skills
Essential
- Knowledge:
- Level 2 qualification in Maths and English (M)
- Understanding of health and social care processes (E)
- Knowledge/familiarity with medical terminology (E)
- Understanding of social determinants of health and how these can be addressed with patients (E)
- High levels of health literacy (E)
- Excellent knowledge of Microsoft products and their use (E)
Desirable
- Knowledge:
- Educated to level 3 in a relevant topic, or working towards (D)
- Knowledge of a range of technology and digital tools that can be used support health and wellbeing (D)
- Understanding of current issues facing the NHS (D)
Vehicle Access
Essential
- As it will be necessary to travel between PCN practice(s) within Middlesbrough, aligned care homes and deliver support to patients within the local community. Therefore it is essential that our care coordinators have access to their own vehicle and hold a current valid divers license.
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.