Job summary
Care
coordinators play an important role within a PCN to proactively identify and
work with people, including care home residents, the frail/elderly, people with
learning disabilities/dementia and those with long-term conditions, to provide
coordination and navigation of care and support across health and care
services.
Regis
Healthcare PCN has recently undergone a review and restructure. This role therefore presents an exciting
opportunity to be part of something new and exciting, where you can influence
the shape of care coordination across the PCN.
Interview Details
Please note, should you be successfully shortlisted, interviews are scheduled to take place on 10th and 11th May.
Main duties of the job
Care Coordinators work closely with GPs and Practice teams to manage a
caseload of patients, acting as a central point of
contact to ensure appropriate support is made available to them and their
carers. They focus on what
matters to patients and support them to understand and manage their condition, ensuring their changing
needs are addressed.
Care coordinators review patients needs, help them access the
services and support they require to understand and manage their own health and
wellbeing and work alongside other
personalised care roles (care coordinators, social prescribing link workers and
health and wellbeing coaches) to provide an
all-encompassing approach to personalised care.
About us
IPC is an innovative and ethical company providing high quality, integrated, patient-focused NHS services. We achieve this by harnessing the collective knowledge, skills, experience and energy of our clinicians and staff. If you believe in the importance and effectiveness of providing excellent care where patients need it and would like to apply, we would love to hear from you.
Benefits of applying:
- NHS Pension
- Flexible working
- Full time and Part time hours available
- Possibility of hybrid working
- Peer Support provided regularly (every 6 weeks)
- Clinical Supervision and Support
Regis Healthcare PCN is made up of the following six practices:
- Arundel Surgery
- Avisford Medical Group
- Bersted Green Surgery
- Bognor Medical Practice
- The Croft
- Flansham Park Health Centre
Job description
Job responsibilities
Coordination Duties
- Improve the care frail patients receive by
coordinating the delivery of their care, proactively identifying unmet care
needs and preventing unnecessary hospital admissions.
- Work with clinical professionals and patients to
createcareplans for frail patients.
- Ensure that all patients on the learning
disability/dementia register receive an annual review in accordance with
protocols.
- Liaise with the learning disability/dementia
lead in each Practice to ensure that timely care is received as needed,
clinical records are updated and annual review documents are up to date.
- Provide coordination support for patients to
navigate health care services and expedite referrals, where necessary, to
providers such as (but not limited to) Proactive care, Care Home Matrons,
Wheelchair Services, Community Nurses, Eyes and Ear Tests, SaLT, OT or Physio,
Dementia Services.
- Document end of life in accordance with protocol
and attend Practice GSF meetings, linking in with the Echo team, where required.
- Coordinate annual Structured Medication Reviews (SMR)
with lead clinicians and MOCH Pharmacists.
- Refer to PCN personal care role workers, social
prescribers and MIND wellbeing workers, where a patient is identified as
potentially benefitting from this service.
- Support the Practice in achieving its Quality
and Outcome Frameworks and other DES/LES specifications.
- Monitor referrals to ensure tasks are completed
and care is delivered by keeping in regular contact with patients and their
representatives.
- Help people to transition seamlessly between
services and support them to navigate through the health and care system, liaising
directly with multiple agencies to coordinate care for patients.
- 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.
- Review and update personalised care and support
plans at regular intervals.
- Assist with the coordination of annual Flu and
Covid vaccines programmes, gaining consent from patients or their
representatives as appropriate, running searches to help with planning and
entering data on the clinical system.
- 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.
Multidisciplinary Working- Support the clinical and social care
professionals in coordinating all key activity, including access to services, Multidisciplinary
Team (MDT) meetings, advice and information and ensuring health and care
planning is timely, efficient and patient-centred.
- Support the setting up, coordination and management
of regular multidisciplinary hub meetings, including but not limited to,
Frailty and Palliative care, to ensure a smooth and coordinated approach,
especially where multiple agencies are involved.
- Develop and coordinate the integrated care team
hub, taking responsibility for a caseload of patients.
- Ensure regular and consistent communication with
referrers regarding patient progress and any complications or guidance
suggested by the MDT.
- Work with other Care Coordinators to develop
knowledge of local services and teams, supporting and assisting each other
through sharing of knowledge and good practice.
- Maintain and develop engagement with all Practice
staff and encourage best practice. Act as a champion for personalised care
and shared decision-making within the PCN.
- Identify opportunities and gaps in the service
and contribute to continuous improvements to the service and business planning.
- Attend bi-weekly proactive care team meetings.
- Attend the PCN Board meetings, as required, to
provide updates on EHiCH work and any other relevant information.
- Attend Practice meetings, when requested.
Care Home Specific Duties (where
applicable)
- Organise a weekly/bi-weekly ward round for each
care home, as required by the allocated Practice, to obtain relevant
information, such as new hospital attendances, falls, medication and updates
regarding residents approaching end of life.
- Ensure all updated information gathered from the
ward round is documented on the patients clinical record.
- Book appointments for care home residents on the
clinical system, as required.
- Discuss personalised care for care home
residents with patients, their families and the care home staff, ensuring the
personalised care and support plans are recorded on the clinical system and the
relevant template is completed.
- Gather appropriate information to record on
ReSPECT forms.
- Discuss the hospital discharges for care home
residents with patients, their relatives and the care home, as appropriate,
ensuring the care plan is updated.
- Align the collection of new patient data/new
patient checks with the requirements of the care home sector, using the new
Care Home Patient Form, ensuring all information is entered onto the clinical
system.
- Organise monthly care homes education meetings
to discuss key topics including, but not limited to, ReSPECT Forms, Proxy
Access, New Care Home Resident forms, Covid/flu vaccinations and consent.
- Coordinate annual structured Medication reviews
with Care Home Matrons.
- Carry out any of the above coordinator duties in
relation specifically to care home residents.
Job description
Job responsibilities
Coordination Duties
- Improve the care frail patients receive by
coordinating the delivery of their care, proactively identifying unmet care
needs and preventing unnecessary hospital admissions.
- Work with clinical professionals and patients to
createcareplans for frail patients.
- Ensure that all patients on the learning
disability/dementia register receive an annual review in accordance with
protocols.
- Liaise with the learning disability/dementia
lead in each Practice to ensure that timely care is received as needed,
clinical records are updated and annual review documents are up to date.
- Provide coordination support for patients to
navigate health care services and expedite referrals, where necessary, to
providers such as (but not limited to) Proactive care, Care Home Matrons,
Wheelchair Services, Community Nurses, Eyes and Ear Tests, SaLT, OT or Physio,
Dementia Services.
- Document end of life in accordance with protocol
and attend Practice GSF meetings, linking in with the Echo team, where required.
- Coordinate annual Structured Medication Reviews (SMR)
with lead clinicians and MOCH Pharmacists.
- Refer to PCN personal care role workers, social
prescribers and MIND wellbeing workers, where a patient is identified as
potentially benefitting from this service.
- Support the Practice in achieving its Quality
and Outcome Frameworks and other DES/LES specifications.
- Monitor referrals to ensure tasks are completed
and care is delivered by keeping in regular contact with patients and their
representatives.
- Help people to transition seamlessly between
services and support them to navigate through the health and care system, liaising
directly with multiple agencies to coordinate care for patients.
- 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.
- Review and update personalised care and support
plans at regular intervals.
- Assist with the coordination of annual Flu and
Covid vaccines programmes, gaining consent from patients or their
representatives as appropriate, running searches to help with planning and
entering data on the clinical system.
- 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.
Multidisciplinary Working- Support the clinical and social care
professionals in coordinating all key activity, including access to services, Multidisciplinary
Team (MDT) meetings, advice and information and ensuring health and care
planning is timely, efficient and patient-centred.
- Support the setting up, coordination and management
of regular multidisciplinary hub meetings, including but not limited to,
Frailty and Palliative care, to ensure a smooth and coordinated approach,
especially where multiple agencies are involved.
- Develop and coordinate the integrated care team
hub, taking responsibility for a caseload of patients.
- Ensure regular and consistent communication with
referrers regarding patient progress and any complications or guidance
suggested by the MDT.
- Work with other Care Coordinators to develop
knowledge of local services and teams, supporting and assisting each other
through sharing of knowledge and good practice.
- Maintain and develop engagement with all Practice
staff and encourage best practice. Act as a champion for personalised care
and shared decision-making within the PCN.
- Identify opportunities and gaps in the service
and contribute to continuous improvements to the service and business planning.
- Attend bi-weekly proactive care team meetings.
- Attend the PCN Board meetings, as required, to
provide updates on EHiCH work and any other relevant information.
- Attend Practice meetings, when requested.
Care Home Specific Duties (where
applicable)
- Organise a weekly/bi-weekly ward round for each
care home, as required by the allocated Practice, to obtain relevant
information, such as new hospital attendances, falls, medication and updates
regarding residents approaching end of life.
- Ensure all updated information gathered from the
ward round is documented on the patients clinical record.
- Book appointments for care home residents on the
clinical system, as required.
- Discuss personalised care for care home
residents with patients, their families and the care home staff, ensuring the
personalised care and support plans are recorded on the clinical system and the
relevant template is completed.
- Gather appropriate information to record on
ReSPECT forms.
- Discuss the hospital discharges for care home
residents with patients, their relatives and the care home, as appropriate,
ensuring the care plan is updated.
- Align the collection of new patient data/new
patient checks with the requirements of the care home sector, using the new
Care Home Patient Form, ensuring all information is entered onto the clinical
system.
- Organise monthly care homes education meetings
to discuss key topics including, but not limited to, ReSPECT Forms, Proxy
Access, New Care Home Resident forms, Covid/flu vaccinations and consent.
- Coordinate annual structured Medication reviews
with Care Home Matrons.
- Carry out any of the above coordinator duties in
relation specifically to care home residents.
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 data collection and using tools to measure the impact of services.
Desirable
- Experience of working directly in a care coordinator role, adult health and social care, learning support or public health/health improvement.
- Experience or training in personalised care and support planning.
- Experience of motivational interviewing and coaching other techniques.
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
Qualifications
Essential
- Must have completed a two-day PCI accredited care coordination training course or be willing to complete one prior to taking referrals.
Additional Criteria
Essential
- Must meet Disclosure and Barring Service (DBS) reference standards and criminal record checks.
- Willingness to work flexible hours, when required, to meet work demands.
- Complete immunisation record
Desirable
- Access to own transport and ability to travel across the locality on a regular basis.
- Proficient speaker of another language to aid communication with people in the community for whom English is a second language.
Skills & Knowledge
Essential
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Understanding of, and commitment to, equality, diversity and inclusion.
Desirable
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes.
Personal Qualities and Attributes
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental manner.
- Commitment to reducing health inequalities and proactively working to reach people from diverse communities.
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Ability to plan, organise and prioritise work, using own initiative. Working under pressure and to deadlines.
- Ability to maintain effective working relationships and to promote collaborative practice with colleagues.
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 data collection and using tools to measure the impact of services.
Desirable
- Experience of working directly in a care coordinator role, adult health and social care, learning support or public health/health improvement.
- Experience or training in personalised care and support planning.
- Experience of motivational interviewing and coaching other techniques.
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
Qualifications
Essential
- Must have completed a two-day PCI accredited care coordination training course or be willing to complete one prior to taking referrals.
Additional Criteria
Essential
- Must meet Disclosure and Barring Service (DBS) reference standards and criminal record checks.
- Willingness to work flexible hours, when required, to meet work demands.
- Complete immunisation record
Desirable
- Access to own transport and ability to travel across the locality on a regular basis.
- Proficient speaker of another language to aid communication with people in the community for whom English is a second language.
Skills & Knowledge
Essential
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Understanding of, and commitment to, equality, diversity and inclusion.
Desirable
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes.
Personal Qualities and Attributes
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental manner.
- Commitment to reducing health inequalities and proactively working to reach people from diverse communities.
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Ability to plan, organise and prioritise work, using own initiative. Working under pressure and to deadlines.
- Ability to maintain effective working relationships and to promote collaborative practice with colleagues.
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.
