Job summary
We are hoping to recruit four dynamic and ambitious Care Coordinators to work within our Primary Care Network multi-disciplinary healthcare team.
Care Coordinators play an important role within GP practices to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. They will ensure patient health and care planning is timely, efficient, and patient-centred and will include responsibilities for the coordination of the patients journey through primary care and secondary care. 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.
The successful candidates will work alongside our existing Personalised Care Team which consists of five Social Prescribing Link Workers, two Health and Wellbeing Coaches and five Care Coordinators to provide a holistic approach to personalised care and will work with a diverse range of people from different cultural and social backgrounds as well as supporting local Integrated Care Partners and services.
Main duties of the job
Care Coordinators enable people to access the services and support they require to meet their
health and wellbeing needs, helping to improve peoples quality of life. The successful candidates will work alongside our existing Personalised Care Team, which consists of 5 social prescribing link workers, 2 health and wellbeing coaches and 5 Care
Coordinators to provide an all-encompassing approach to personalised care and
enable people navigate through the health and care system. They will
work with a diverse range of people from different cultural and social
backgrounds and the ability to work confidently and effectively in a varied, and
sometimes challenging environment is essential. The successful candidates will
have excellent interpersonal and communication skills, and be organised,
patient and empathetic. They will have experience of working in health, social
care or other support roles including direct contact with people, families or
carers.
About us
With a combined patient population of just over 57,000 across our six practices, Cambridge City 4 PCNs vision is to work together to deliver the best possible outcomes for our patients and staff. We are an innovative, forward-thinking organisation and we are looking for individuals with drive, ambition, compassion, vision and enthusiasm. We place great value on personal development within our organisation and the role of Care Coordinator can offer the right candidate an exciting and rewarding career in Primary Care.
Job description
Job responsibilities
-
Work with people, their families and carers to improve their understanding of
the patients condition and support them to develop and review personalised
care and support plans to manage their needs and achieve better healthcare
outcomes.
-
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.
-
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.
-
Support people to take up training and employment, and to access appropriate
benefits where eligible; for example, through referral to social prescribing
link workers.
-
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; helping to ensure
patients receive a joined-up service and the most appropriate support.
-
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 coordination 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 patients to be more prepared to have
shared decision-making conversations.
-
Explore and assist people to access a personal health budget where appropriate
- Work
with people, their families, carers and healthcare team members to encourage
effective help-seeking behaviours;
-
Support PCNs in developing communication channels between GPs, people and their
families and carers and other agencies;
-
Identify unpaid 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;
- Work with commissioners, integrated locality teams and other agencies to
support and further develop the role.
Key
Tasks
- Enable access to personalised
care and support
- Take referrals for individuals
or proactively identify people who could benefit from support through care
coordination;
- Have a positive, empathetic and
responsive conversation with the person and their family and carer(s) about
their needs;
- Work towards increasing
patients understanding of how to manage and develop health and wellbeing through
offering advice and guidance;
- Develop an in-depth knowledge
of the local health and care infrastructure and know how and when to enable
people to access support and services that are right for them;
- Use tools to measure peoples levels of
knowledge, skills and confidence in managing their health and to tailor support
to them accordingly.
- Work with the wider PCN, MDTs,
and the social prescribing service to look at how carers can support people -
this could include the initial identification of carers onto the carer register
- Support people to develop and
implement personalised care and support plans;
- Review and update personalised
care and support plans at regular intervals;
- 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;
- Where a personal health budget
is an option, to work with the person and the local CCG team to provide advice
and support as appropriate;
Coordinate
and integrate care
- Making and managing
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 wider the health and
care system;
- Refer onwards to social
prescribing link workers and health and wellbeing coaches where required;
- Regularly liaise with the range
of multidisciplinary professionals and colleagues involved in the persons
care, facilitating a coordinated 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 as and when appropriate;
- 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 coordination on their health and wellbeing;
- Encourage people, their
families and carers to provide feedback and to share their stories about the
impact of care coordination on their lives;
- Record and collate information
according to agreed protocols and contribute to evaluation reports required for
the monitoring and quality improvement of the service.
Professional
development
- Work with a named clinical
point of contact for advice and support
- 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.
Miscellaneous
- Establish strong working
relationships with GPs and practice teams and work collaboratively with other care
coordinators, social prescribing link workers and health and wellbeing coaches,
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;
- Identify opportunities and gaps
in the service and provide feedback to continually improve the service and
contribute to business planning;
- 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; Contribute to the wider aims and
objectives of the PCN to improve and support primary care
Job description
Job responsibilities
-
Work with people, their families and carers to improve their understanding of
the patients condition and support them to develop and review personalised
care and support plans to manage their needs and achieve better healthcare
outcomes.
-
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.
-
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.
-
Support people to take up training and employment, and to access appropriate
benefits where eligible; for example, through referral to social prescribing
link workers.
-
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; helping to ensure
patients receive a joined-up service and the most appropriate support.
-
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 coordination 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 patients to be more prepared to have
shared decision-making conversations.
-
Explore and assist people to access a personal health budget where appropriate
- Work
with people, their families, carers and healthcare team members to encourage
effective help-seeking behaviours;
-
Support PCNs in developing communication channels between GPs, people and their
families and carers and other agencies;
-
Identify unpaid 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;
- Work with commissioners, integrated locality teams and other agencies to
support and further develop the role.
Key
Tasks
- Enable access to personalised
care and support
- Take referrals for individuals
or proactively identify people who could benefit from support through care
coordination;
- Have a positive, empathetic and
responsive conversation with the person and their family and carer(s) about
their needs;
- Work towards increasing
patients understanding of how to manage and develop health and wellbeing through
offering advice and guidance;
- Develop an in-depth knowledge
of the local health and care infrastructure and know how and when to enable
people to access support and services that are right for them;
- Use tools to measure peoples levels of
knowledge, skills and confidence in managing their health and to tailor support
to them accordingly.
- Work with the wider PCN, MDTs,
and the social prescribing service to look at how carers can support people -
this could include the initial identification of carers onto the carer register
- Support people to develop and
implement personalised care and support plans;
- Review and update personalised
care and support plans at regular intervals;
- 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;
- Where a personal health budget
is an option, to work with the person and the local CCG team to provide advice
and support as appropriate;
Coordinate
and integrate care
- Making and managing
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 wider the health and
care system;
- Refer onwards to social
prescribing link workers and health and wellbeing coaches where required;
- Regularly liaise with the range
of multidisciplinary professionals and colleagues involved in the persons
care, facilitating a coordinated 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 as and when appropriate;
- 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 coordination on their health and wellbeing;
- Encourage people, their
families and carers to provide feedback and to share their stories about the
impact of care coordination on their lives;
- Record and collate information
according to agreed protocols and contribute to evaluation reports required for
the monitoring and quality improvement of the service.
Professional
development
- Work with a named clinical
point of contact for advice and support
- 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.
Miscellaneous
- Establish strong working
relationships with GPs and practice teams and work collaboratively with other care
coordinators, social prescribing link workers and health and wellbeing coaches,
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;
- Identify opportunities and gaps
in the service and provide feedback to continually improve the service and
contribute to business planning;
- 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; Contribute to the wider aims and
objectives of the PCN to improve and support primary care
Person Specification
Qualifications
Essential
- GCSE grade A-C in Maths & English
Desirable
- NVQ level 3 in health/care related subject
Experience
Essential
- * Ability to actively listen, empathise 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
- * 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, community groups, partner agencies and stakeholders
- * Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when the needs of that person is beyond the scope of a Care Coordinator
- * Ability to develop and maintain effective working relationships with colleagues
- * Ability to demonstrate personal accountability, emotional resilience and work well under pressure
- * Ability to organise, plan and prioritise on own initiative
- * Experience of working in a patient/customer facing role
- * Experience of working within multidisciplinary teams
- * Experience of supporting people, their families and carers in a related role
- * Knowledge of personalised care approach
- * Understanding of the wider determinants of health, including social, economic and environmental factors
- * Excellent organisational skills, time management and record keeping
Desirable
- * Experience of working within health care setting - ideally Primary Care/General Practice
- * Experienced in JOY, SystemOne or EMIS clinical systems
- * Experience of successful partnership working across multiple organisations
- * Knowledge of safeguarding and working with vulnerable people
- * Proficient speaker of another language to aid communication with people in the community for whom English is a second language
Person Specification
Qualifications
Essential
- GCSE grade A-C in Maths & English
Desirable
- NVQ level 3 in health/care related subject
Experience
Essential
- * Ability to actively listen, empathise 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
- * 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, community groups, partner agencies and stakeholders
- * Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when the needs of that person is beyond the scope of a Care Coordinator
- * Ability to develop and maintain effective working relationships with colleagues
- * Ability to demonstrate personal accountability, emotional resilience and work well under pressure
- * Ability to organise, plan and prioritise on own initiative
- * Experience of working in a patient/customer facing role
- * Experience of working within multidisciplinary teams
- * Experience of supporting people, their families and carers in a related role
- * Knowledge of personalised care approach
- * Understanding of the wider determinants of health, including social, economic and environmental factors
- * Excellent organisational skills, time management and record keeping
Desirable
- * Experience of working within health care setting - ideally Primary Care/General Practice
- * Experienced in JOY, SystemOne or EMIS clinical systems
- * Experience of successful partnership working across multiple organisations
- * Knowledge of safeguarding and working with vulnerable people
- * Proficient speaker of another language to aid communication with people in the community for whom English is a second language
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.