Care Coordinator

Job description

Job responsibilities

Care coordinators provide extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. They focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification.

· Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids.

· Bring together all of a person’s identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice.

· Help people to manage their needs, answering their queries and supporting them to make appointments.

· Support people to take up training and employment, and to access appropriate benefits where eligible.

· Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision making conversation.

· Ensure that people have good quality information to help them make choices about their care,

· Support people to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing, including through use of the Patient Activation Measure.

· Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.

· Explore and assist people to access personal health budgets where appropriate.

· 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.

· Identify where technology can be utilised to support continued care or aid remote monitoring of health and wellbeing

· Support the implementation of digital technologies that promote new ways of working across the network

· Communicate effectively and sensitively and use language appropriate to a patient and carer/relative’s condition and level of understanding

· Effectively use all methods of communication and be aware of and manage barriers

· Support the coordination and delivery of MDTs within PCNs.

Digital and informatics requirements

· Extracting data from electronic patient records, electronic patient information systems, and other systems and sources consistent with measures and data collection definitions to support continuous improvement

· Devising, modifying, maintaining and/or updating appropriate databases and spreadsheets consistent with agreed measures and definitions

· Work collaboratively with the PCN Network Manager in the development and implement a robust reporting system to support continuous improvement and learning

· To support the development and updating of PCN templates so that information captured is accurate and easily extractable

· Take a lead role within the PCN IT working group, supporting the development of IT processes and tools to improve PCN reporting requirements

· Support PCN staff with related IT / information requests

· Horizon scan for innovate digital solutions to improve workload and address identified workforce pressures across the network

Stakeholder Relationships

· Work as part of the wider holistic team to provide cover and support as necessary

· To work with our clinical and digital system colleagues to implement and operate technology solutions which may include wearables or equipment to enable self-taking of health diagnostics e.g. blood pressure, weight etc.

· Build and maintain relationships with primary, secondary, community and voluntary leads and members of the local support team including named GPs, pharmacist, community nursing team, therapists, mental health professionals etc.

Collaborative working relationships:

· Work within the primary care team, contributing to leadership of service evaluation to promote quality improvement activity.

· Collaborate with members of the PCN, patients and their carers when managing and co-ordinating care.

· Work in partnership with members of the PCN workforce including medical, nursing, pharmacy, other care co-ordinators, link worker, health coaches to personalise care

Management:

· Use resources effectively to manage clinic delivery in line with local and local guidance and makes recommendations for change where improvements can be made.

· Follows professional and organisational policies

· Education, learning and development:

· Engage in training, set out in the Personalised Care Institute Curriculum https://www.personalisedcareinstitute.org.uk/pluginfile.php/133/mod_page/content/22/PCI_Curriculum.pdf

· Comply with all organisational and statutory requirements (health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance).

· Engages in developing objectives to inform a Personal Development Plan,

· Supports practice staff and responds to requests for advice and assistance.

· Complete all mandatory and statutory training required by the role.

· Takes responsibility for personal development, learning and performance

· Undertakes additional training where necessary to provide enhanced services and participate in training programmes implemented by the PCN/practices as part of this employment.

· Understands and demonstrates the characteristics of a role model to members in the team and/or service.

· Demonstrates an understanding of current educational policies relevant to working areas of practice and keeps up to date with relevant clinical practice.

· Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.

Quality:

Under supervision and support of GPs and the wider team, the post-holder will strive to maintain quality within the PCN, and will:

· Participate in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and Quality Improvement

· Alerts other team members to concerns about risk, quality, and safety

· Participates in investigation of incidents and events as required

· Identify, applies, and disseminates research findings relating to current practice

· Collect data for audit purposes and uses clinical audit to monitor quality in the service

· Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team performance

· Work effectively with individuals in other agencies to meet patient needs

· Effectively manage own time, workload, and resources

Equality and Diversity:

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

· Act in a way that recognises the importance of people’s rights, interpreting them in a way that is consistent with Practices procedures and policies, and current legislation.

· Respect the privacy, dignity, needs and beliefs of patients, carers and colleagues.

· Behave in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feeling priorities and rights.

Person Specification

Experience

Essential

• Ability to actively listen and 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, community groups, 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 work from an asset-based approach, building on existing community and personal assets
• 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
• High level of written and verbal communication skills
• 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
• 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
• Knowledge of the personalised care approach
• 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
• Ability to recognise and work within limits of competence and seek advice when needed
• 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
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Good communicator
• Professional, approachable and respectful attitude to others
• Evidence of coaching approach to supporting individuals
• An ability to provide constructive feedback and receive feedback in a professional manner.
• Recognises the roles of other colleagues and their role to person centred care
• Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary
• Demonstrate a high level of personal honesty and integrity

Desirable

• Ability to provide motivational coaching to support peoples behaviour change
• 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 working with elderly or vulnerable people, complying with best practice and relevant legislation
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes

Qualifications

Essential

• Demonstrable commitment to professional and personal development
• Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook

Desirable

• NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
• Understanding / experience of healthcare

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

Aintree PCN

Address

Long Lane Medical Centre

Long Lane

Walton

Liverpool

L9 6DQ

Employer's website

https://www.aintreeparkgrouppractice.nhs.uk/ (Opens in a new tab)