Job summary
We are expanding our PCN team and
have an exciting opportunity for a Learning Disability Care Coordinator to
provide timely accurate information and effective support to people diagnosed
with a Learning Disability, their carers and family. The service will provide
yearly health reviews, practical facilitation, and interventions to promote
independence and wellbeing. The Learning Disability Care Coordinator will work
in conjunction with a multi-disciplinary team of professionals across the
health and social care system to assess needs and identify and agree person
centred outcomes to improve quality of life.
Main duties of the job
Improve the health and wellbeing of adults
with a learning disability, through provision of personalised care and
support coordination within primary care. Strive to improve significant
health inequalities and premature deaths for those with a Learning Disability. This role will identify, empower and
support people, assess their needs and work with partners, care providers and
other stakeholders to develop a comprehensive personalised plan centred
around what matters to the person to improve their health and wellbeing and
to live well in the community.
About us
Portsdown Group Practice covers the whole of Portsmouth from postcodes PO1 to PO7. We operate from 6 surgeries: Cosham Park House (PO6 3BG), Crookhorn Lane (PO7 5XP, Heyward Road (PO4 0DY), Kingston Crescent (PO2 8AL), Paulsgrove (PO6 4HJ), and Somerstown (PO5 4EZ).
We are our own Primary Care Network (PCN). We have Clinical Partners, Salaried GPs and a comprehensive Nursing and extended clinical team overseen by our Clinical Team Manager and consisting of Nurse / Paramedic Practitioners, Registered Nurses, HCA’s, MSK Physiotherapists, Podiatrist, Dietitian, Social Prescribers and Care Co-ordinators. The Pharmacy team consists of Clinical Pharmacists, Pharmacy Technicians and Pre-Registration Trainee Pharmacy Technician.
The Practice is well established, financially secure and successful. Over the last few years we have earned maximum QOF points.
Job description
Job responsibilities
- Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care (Adults with a Learning Disability)
- Work with the GPs and other primary care professionals within the Primary Care Network to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN;
- Support patients to utilise decision aids in preparation for a shared decision-making conversation
- Holistically bring together all of a person’s 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
- Support people to take up training and employment, and to access appropriate benefits where eligible
- Support people to take up health checks, flu vaccinations and other primary care services
- 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
- 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; https://www.england.nhs.uk/personalisedcare/supporting-health-and-care-staff-to-deliver-personalised-care/personalised-care-institute/
- Explore and assist people to access personal health budgets where appropriate
- 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
- Support the coordination and delivery of Multi-Disciplinary Teams within the PCN for this client group
- Raise awareness within the PCN of shared decision making and decision support tools
- 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.
- Ensure that organisations and groups to whom patients are directed have basic safeguarding processes in place for vulnerable individuals; and provide opportunities for the patient to develop friendships and a sense of belonging, as well as to build knowledge, skills and confidence.
- Raise and discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with management and if appropriate GPs
- Report regularly to the CTM on key indicators, including take up of flu vaccinations, health screening, long term condition surveillance, having a PSCP in place and reviewed.
- Liaise closely with each GP practice within the PCN to understand the specific needs and issues and ensure the service is tailored accordingly, adding value
Job description
Job responsibilities
- Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care (Adults with a Learning Disability)
- Work with the GPs and other primary care professionals within the Primary Care Network to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN;
- Support patients to utilise decision aids in preparation for a shared decision-making conversation
- Holistically bring together all of a person’s 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
- Support people to take up training and employment, and to access appropriate benefits where eligible
- Support people to take up health checks, flu vaccinations and other primary care services
- 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
- 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; https://www.england.nhs.uk/personalisedcare/supporting-health-and-care-staff-to-deliver-personalised-care/personalised-care-institute/
- Explore and assist people to access personal health budgets where appropriate
- 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
- Support the coordination and delivery of Multi-Disciplinary Teams within the PCN for this client group
- Raise awareness within the PCN of shared decision making and decision support tools
- 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.
- Ensure that organisations and groups to whom patients are directed have basic safeguarding processes in place for vulnerable individuals; and provide opportunities for the patient to develop friendships and a sense of belonging, as well as to build knowledge, skills and confidence.
- Raise and discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with management and if appropriate GPs
- Report regularly to the CTM on key indicators, including take up of flu vaccinations, health screening, long term condition surveillance, having a PSCP in place and reviewed.
- Liaise closely with each GP practice within the PCN to understand the specific needs and issues and ensure the service is tailored accordingly, adding value
Person Specification
Experience
Essential
- Experience of supporting people with a learning disability, their families, and carers in a related role
- Ability to work independently and within a team
Desirable
- Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement
- Experience of collaborative working and building relationships across varied organisations
Skills
Essential
- Good experience of IT systems and packages, data collection and providing monitoring information and proficient in the use of Microsoft Office
- Ability to follow policies, procedures, and care pathways
- Excellent communication and listening skills including ability to communicate effectively, both verbally and in writing, with a wide range of people and stakeholders
- Excellent administration and record keeping skills including ability to prioritise and finish tasks
Qualifications
Essential
- Good Standard of Education
Knowledge
Desirable
- Learning Disabilities annual review process in Primary Care
Person Specification
Experience
Essential
- Experience of supporting people with a learning disability, their families, and carers in a related role
- Ability to work independently and within a team
Desirable
- Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement
- Experience of collaborative working and building relationships across varied organisations
Skills
Essential
- Good experience of IT systems and packages, data collection and providing monitoring information and proficient in the use of Microsoft Office
- Ability to follow policies, procedures, and care pathways
- Excellent communication and listening skills including ability to communicate effectively, both verbally and in writing, with a wide range of people and stakeholders
- Excellent administration and record keeping skills including ability to prioritise and finish tasks
Qualifications
Essential
- Good Standard of Education
Knowledge
Desirable
- Learning Disabilities annual review process in Primary Care
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.
