Job responsibilities
The care coordinator will involve proactive management and case finding in order to maintain a person’s independence. They will have a role in supporting and empowering people to become their own Care Co-ordinators with the ultimate aim of them becoming independent and resilient, taking responsibility for managing their own care and living well. The post holder is expected to work within the ICC and Frailty operational guidelines, with particular reference to standardised approaches to case management, care planning and MDT working. The post holder will work closely with the other members of the primary care team and complex care teams in the management/decision making about care and service provision for individual patients of low to medium complexity who will usually have one or more long term conditions.
They will:
Use the eFi moderately frail reports to proactively target patient groups within this cohort. Using EMIS searches where necessary to target individuals e.g. following hospital admission, infection or other local criteria. Cases will also be allocated via the local GP practice or community Hub
Carry out a holistic, person centred assessment which looks at the health and social needs of the person, conducted in partnership with the individual person, their family and carers. The assessment will be conducted, whenever possible, in the persons own home to take account of environmental factors and to fully understand the person’s functional ability in a familiar setting.
Develop and agree a Support Plan containing actions covering the short and medium-terms. Where necessary identifying urgent needs taking relevant action or liaison
Implement the Support Plan by setting up services using the appropriate procedures and systems and coordinating health and social care support that is being delivered, ensuring it meets the needs of the individual and is patient centred.
Provide non-clinical interventions such as advice, guidance and direct support to patients on their caseload
Arrange for relevant equipment including making use of telecare to increase the person’s independence
Conduct low level clinical screening such as dementia screening, urine and blood testing, as directed by the GP or other lead health professional
Carry out home environmental checks including falls risk assessments and take appropriate actions to prevent falls
Provide low level care such as medicine prompts where deemed appropriate
Refer and liaise with a range of voluntary sector support agencies, ensuring the patient has access to a wide range of support
Where requested, provide support which contributes to a severely frail person’s care plan by participating in meetings; coordinating information and care requirements with other care providers, and reducing overlap/repetition with other practitioners
Monitor and review care plans and agreed outcomes in partnership with the person and to evaluate outcomes. Additionally this would involve re-negotiating care plans as and when required
Provide personalised support to individuals, their families, and carers to support them to be active participants in their own healthcare; empowering them to manage their own health and wellbeing and live independently
Provide interventions such as self-management education and peer support;
Supporting personal choice and positive risk taking while ensuring that patients understand the accountability of their own actions and decisions, thus encouraging the proactive prevention of further illnesses;
Provide a central, continuous point of contact for the person (and their family/carers) and the range of professionals involved in the care package
Act as the key advocate for the person as and when required
Assist the person in the successful navigation of complex health and social care systems
Where appropriate refer the person for a medication review.
Input relevant information into patient records, ensuring complete and accurate case records are maintained
Increasing patient motivation to self-manage and adopt healthy behaviours;
Ensure referrals are responded to in a timely manner, communicating with referrers when necessary, enabling confidence in the service and ensuring patients receive a prompt response.
Identify and engage effectively in a non-judgemental and respectful manner with members of the community from all backgrounds, abilities and ages, listening and interpreting complex health information into understandable terms about health and health improvement.
Seek advice from the patient’s GP or practice lead GP as appropriate.
Ensure patients’ and their families/carers views are taken into account in every stage of the decision making process.
Develop strong links with local VCSE organisations, community and neighbourhood level groups using their networks to have an up to date menu of options available locally.
Be proactive in the community and patient network to encourage referrals from a range of professionals, from patients, their families and carers and local organisations.
Be responsible for the promotion of the service via patient groups, local network groups, websites and other media.
Communication
Link/liaise with local strategic groups (e.g. ICCs/PCN) to ensure work is aligned with local health and wellbeing priorities.
Establish positive working relationships and effective communication with the Copeland GP Practices, integrated care health and care teams, and a range of local voluntary sector and community organisations.
Utilise and demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment.
Communicate effectively to overcome communication barriers with patients and the general public displaying emotional crisis, vulnerability, verbal/ physical aggression, learning difficulties, recognising the need for alternative methods of communication.
Ability to cope with frequently challenging, diverse and stressful situations.
Admin & Professional
To use highly developed knowledge and skills to provide high standards of patient centred care.
To maintain accurate contemporaneous records on all aspects of the care process and patient contact.
To ensure that all project paperwork e.g. performance information is completed and available in a timely manner.
Provide intelligence to the system on the impact of patient lifestyle changes via outcome measure reporting.
Contribute to the development of the service, e.g. developing service pathways, paperwork and sharing good practice.
Awareness of, and compliance with, all relevant local/clinical policies and guidelines.
Participate in data collection data for audit purposes and be responsible for monitoring progress against key performance targets.
Effectively manage own time, workload and resources.
Value and respect colleagues, other members of staff and patients and show commitment to working as a team member.
To attend and participate in practice clinical meetings and other multi-disciplinary meetings where necessary.
Confidentiality
In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.
In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. All such information from any source is to be regarded as strictly confidential.
Information relating to patients, carers, colleagues, other health care workers or the business of the Practices may only be divulged to authorised persons in accordance with policies and procedures relating to confidentiality and the protection of sensitive data.
Equality & Diversity
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 people’s rights, interpreting them in a way that is consistent with procedures and policies, and current legislation;
Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
Education
Participate in clinical supervision
To be accountable for own professional development including compliance with all mandatory training such as Safeguarding and Information Governance.
Making effective use of training to update knowledge and skills
Health & Safety
Under the Health and Safety at Work Act 1974, as an employee, you must take reasonable care for the health and safety of yourself and for other persons who may be affected by your acts or omissions at work. The Act also states that you must not intentionally or recklessly interfere with or misuse anything provided in the interests of health, safety and welfare.
Use personal security systems within the workplace according to local guidelines
Identify risks involved in work activities and undertaking such activities in a way that manages risks
You are also required to make yourself aware of the site health and safety policy and how to report any accidents/incidents.