Care Coordinator

Job description

Job responsibilities

The Care Coordinator role is a critical and an evolving post to support Multi-Disciplinary Teams within Boston Primary Care Network (PCN) to deliver effective, co-ordinated care for vulnerable and frail adults, particularly those at high risk of hospital emergency admissions, ED attendances and unplanned episodes of care.

The Care Coordinator will work very closely with the PCN GP Practices, the Neighbourhood Team and wider stakeholders within Boston. The role is pivotal in ensuring all people receive the best possible coordinated care and access to services. The Care Coordinators role will support GP practice colleagues and the Multi-Disciplinary Team in coordinating all key activity including access to services, MDT meetings, advice, and information, and ensuring health and care planning is timely, efficient, and person-centred. The role will include supporting digital initiatives and includes responsibility for the co-ordination of peoples journey through the health and care system.

The Care Coordinator will also contribute to the development of new ways of integrated working with PCN and Neighbourhood colleagues to achieve better joined up personalised care.

Applicants should have:

• A full UK driving License and suitable access to transport to be able to travel to sites within the PCN area
• An ability to work from home
• DBS check conducted by Boston PCN upon job offer

JOB RESPONSIBILITIES

Main Duties

• Support the Multi-Disciplinary Team with day to day duties
• To work as a key member of the EHCH and Locality MDTs to help create and embed the new structures and processes for better joined up working. To liaise with the registered GP and wider primary care team and other services to coordinate a persons care.
• With support, implement and review individual care plans, self-management plans and to agree trigger thresholds for escalation.
• Provide enhanced support to Nursing and Residential homes with a focus on strengthening relationships and improving access through information sharing, education and advice.
• To coordinate the development and review of peoples care plans.
• Communicate any care plans to the GP and any other members of the EHCH MDT or Neighbourhood Team involved in the persons care and upload to the relevant records.
• Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles
• Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers.
• Provide support to individuals, their families and carers to take control of their health and wellbeing, live independently and improve their health outcomes, as a key member of the PCN multi-disciplinary team.
• To provide coordination and navigation with the aid of digital tools for people and their carers across health and care services
• To attend MDT meetings as appropriate and act as deputy chair as needed.
• Maintain accurate and up to date records of peoples contacts using GP record systems and other IM&T systems relevant to the role.

Administrative Duties

• Under guidance, take initiative in the organisation and administration of MDT meetings including supporting the coordination and delivery of MDTs to minimise the demands upon the multidisciplinary team.
• Manage agenda items, ensuring all new referrals and cases for discussion are identified and information circulated to team members in advance of the meetings.
• To ensure that action points identified within the MDT are recorded and followed up.
• Support the MDT in developing their risk-profiling strategies and tools to identify at risk patients, including those people who have multiple hospital admissions, ED attendances and unplanned out of hours care and implement an agreed structured process on how this information will be fed into MDTs.
• To work with the wider MDT to identify appropriate case managers for high risk people to ensure that they are reviewed and anticipatory care plans are developed.
• Ensure that all peoples Care Plans, Treatment Escalation Plans, DNARs and associated reviews & person-related correspondence are available at the MDT meetings, liaising with all agencies as appropriate, accessing & auditing IT systems to ensure relevant information is available.
• To liaise with acute hospitals regularly, cross referencing admission data with the at risk list, and coordinating the sharing of key information between the acute hospital teams, care/nursing homes and the clinical lead of the EHCH.
• Under the guidance assist with the discharge process to reduce length of stay in the acute / community hospital setting

Other Responsibilities

• To assist the PCN in setting and realising the PCN vision, mission and values
• To play a role in the delivery of high-quality primary health care services
• Maintain a working relationship with local health and care providers enable service delivery of mutual benefit and build a network and knowledge of referral routes to and from service providers.
• To establish and maintain effective liaison with stakeholders including health, voluntary, social and education resources, attending relevant meetings as necessary
• Refer people and/or introduce them to appropriate organisations in Boston and nationally (where appropriate) e.g. voluntary, statutory (local authority) and local NHS organisations.
• To represent the PCN in cross organisation meetings when agreed e.g. locality/CCG meetings
• Collate feedback / analysis data on behalf of the PCN to report to the PCN Board and CCG/NHSE as required
• Support the PCN Manager in providing KPI reports for submission as requested.
• Be responsible for the organisation, planning and of own workload to meet set deadlines.
• Following PCN and practice policies and procedures as appropriate.

Duties will vary from time to time under the direction of the Clinical Directors dependent on current and evolving PCN workload and staffing levels.

KEY WORKING RELATIONSHIPS

• Local care homes
• PCN EHCH Multi-Disciplinary Team
• Local Neighbourhood Team
• Primary Care team within the PCN
• Social Prescribers
• PCN Clinical Pharmacists
• PCN Clinical Director and Manager
• Clinical Commissioning Group (CCG) and NHSE
• Community Health Teams both physical and mental health
• Local Authority
• Adult Social Care
• Third sector and community groups

EQUALITY AND DIVERSITY

All staff through their behaviours and actions will ensure that our services and employment practices are respectful of individual needs and differences including those characteristics covered by the Equality Act 2010 (Age, Disability, Gender Reassignment, Marriage and Civil Partnership, Pregnancy and Maternity, Race, Religion and Belief, Sex and Sexual Orientation).

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

• Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with PCN and practice procedures and policies, and current legislation
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues and acting in a kind and considerate manner.
• Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

PERSONAL/PROFESSIONAL DEVELOPMENT

The post-holder will participate in any training programme implemented by the PCN as part of this employment, with such training to include:

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

QUALITY

The post-holder will strive to maintain quality within the practice, and will:

• Alert other team members to issues of quality and risk
• Assess own performance and take accountability for own actions, either directly or under supervision
• Contribute to the effectiveness of the team by reflecting on own and team activities andmaking suggestions on ways to improve and enhance the teams performance
• Work effectively with individuals in other agencies to meet patients needs
• Effectively manage own time, workload and resources

Person Specification

Qualifications

Essential

• GCSE (A* - C) or equivalent in Maths and English
• Evidence of continuing professional development
• Experience in care coordination or clinical administration

Desirable

• Experience in a health or social care profession

Experience

Essential

• Computer literate with a the ability to use Microsoft Office Programs such as Word and Excel competently with some experience of the other programs of the Microsoft Office package
• Understand the aims of current healthcare policy within the PCN
• Able to analyse and interpret data
• Has attention to detail, able to work accurately, identifying errors quickly and easily
• Has a planned and organised approach with an ability to prioritise their own workload to meet strict deadlines
• Able to think analytically; anticipating obstacles and thinking ahead; using analytical techniques to draw logical solutions to problems
• Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience
• An excellent understanding of data protection and confidentiality issues
• Able to arrange suitable meetings with multiple individuals with often conflicting priorities

Desirable

• Working knowledge of SystmOne

Attributes

Essential

• Enthusiasm, drive and the ability to cope in challenging situations
• Works effectively independently and as a member of a team
• Flexible approach to meet service needs and ensure a stakeholder focused response
• Self-motivated and proactive
• Continued commitment to improve skills and ability in new areas of work
• Able to undertake the demands of the post with reasonable adjustments if required
• Able to access transport to work across the practices within the PCN and attend meetings in other locations
• Adaptability, flexibility and ability to cope with uncertainty and change
• Demonstrate ability to work in a busy environment; ability to deal with both urgent and important tasks and to prioritise effectively whilst also supporting others
• Excellent time keeping and prioritisation skills

Desirable

• Ability to work from home on some occasions where tasks allow

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

Boston Primary Care Network

Address

Parkside Medical Centre

Tawney Street

Boston

Lincolnshire

PE21 6PF