Care Coordinator

Job description

Job responsibilities

Job Summary / Purpose of the role

One Ellesmere Port Primary Care Network (PCN) is a collaboration of the 6 GP Practices across Ellesmere Port working together to care for and provide services to 72,000+ patient population. The PCN is looking for an innovative PCN Care Coordinator to work at York Road Group Practice and to join our wider PCN Care Coordinator team. The post holder will work closely with their GP Practice team and the PCN Team Care Coordinator to ensure the efficient operation of PCN services, with a specific focus on supporting the delivery of the PCNs Vaccination Programme (Flu, Covid-19 and RSV) during seasonal campaigns.

Care Coordinators play an important role within a PCN to proactively identify and work with various groups of people, including the frail / elderly, those with long-term conditions and other vulnerable groups to provide co-ordination and navigation of care and support across health and care services.

They 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 people and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.

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 can provide time, capacity and expertise to support people in preparing for, or following-up, clinical conversations. Enabling patients to be more actively involved in managing their care and supporting them to make choices that are right for them. Care co-ordinators help people improve their quality of life.The successful candidate will be dedicated to York Road Group Practice patients. They will be caring, dedicated, reliable, person-focussed 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.

This role is intended to become an integral part of the PCNs multidisciplinary team, working alongside our Social Prescribing Link Workers, Health & Wellbeing Coaches, Mental Health Occupational Therapists and Dementia Practitioner to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach within your practice and across the PCN.

There may be a need to work at other sites depending on the requirements of the role. Please note that the Care Coordinator works under delegation of a registered health professional.

Key Responsibilities

• To work with the PCN Team Care Coordinator to ensure the smooth and efficient delivery of the PCN seasonal Vaccination Programmes and other PCN projects.
• Work with people, their families and carers, to improve their understanding of their condition.
• Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
• Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
• Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.
• Provide co-ordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.
• 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 co-ordination 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 people to be more prepared to have shared decision-making conversations.
• Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours.
• Identify carers and help them access services to support them.
• Conduct follow-ups on communications from out of hospital and in-patient services.
• Maintain records of referrals and interventions to enable monitoring and evaluation of the service.
• Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances.

The above is not an exhaustive list. The successful candidate may be asked to complete tasks in line with the overall objectives of the organisation and PCN agenda. These duties will be reviewed regularly with the job holder with an aim of developing the scope of the role.

Key Tasks:

Enable Access to Personalised Care and Support

• Take referrals or proactively identify people who could benefit from support through care coordination.
• 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.

Coordinate and Integrate Care

• Make and manage appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
• Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system.
• Refer onwards to social prescribing link workers, health and wellbeing coaches, Mental Health Occupational Therapists and Dementia Practitioner 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.

Supervision / Professional Development

• 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.
• Access regular supervision.

Miscellaneous

• Establish strong working relationships with GPs and practice teams and work collaboratively with other care co-ordinators, social prescribing link workers, health and wellbeing coaches, Mental Health Occupational Therapist and Dementia Practitioner 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.
• 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.

Professional Development

All employees will be expected to complete all mandatory training as instructed by the organisation and complete additional training as and when required. The post holder must have the ability to reflect on practice, identify learning needs and take responsibility for continued professional development (with line management support).

Confidentiality

Working within the PCN employees may gain knowledge of confidential matters which may include personal and medical information about patients and staff. All information, either written or electronic, must be treated as strictly confidential at all times, and must not be divulged to any other person unless it is appropriate to do so.

Person Specification

Other

Essential

• Meets a Disclosure and Barring Service (DBS) reference standards and criminal record checks
• Willingness to work flexible hours when required to meet work demands, especially during the seasonal Vaccination Programme
• Access to own transport

Desirable

• Ability to travel across the locality on a regular basis

Skills & Knowledge

Essential

• Understanding of personalised care and the comprehensive model of personalised care
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Knowledge of how the NHS works, including primary care and PCNs
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social

Desirable

• Ability to recognise and work within limits of competence and seek advice when needed

Personal Qualities

Essential

• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• 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 communicate effectively, both verbally and in writing, with people, their families, carers, 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 the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
• 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
• Demonstrable commitment to professional and personal development
• Experience using EMIS
• Proficient in MS Office and web -based services

Desirable

• Ability to provide motivational coaching to support peoples behaviour change

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
• Experience of data collection and using tools to measure the impact of services

Desirable

• Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement
• Experience or training in personalised care and support planning
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

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

York Road Group Practice

Address

York Road

Ellesmere Port

Cheshire

CH65 0DB

Employer's website

https://www.yorkroadgrouppractice.co.uk/gp/ (Opens in a new tab)