Job summary
Care
coordinators play an important role within a PCN 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
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 them 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.
Main duties of the job
Care coordinators review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.
Their aim is to help people improve their quality of life.
The successful candidate will be caring, dedicated, reliable and person-focused 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.
About us
Eden Primary Care Network (PCN) and its ten constituent GP Practices are working together to improve the health and well-being of the Eden population and provide high quality, integrated services across the community.
Job description
Job responsibilities
Main
duties/Key tasks:
- Undertake
comprehensive geriatric assessment and/or annual review on all patients scoring
moderate to severe on the practice frailty register
- Keep
care records up to date by identifying and updating missing or out-of-date
information about the persons circumstances;
- Highlight
any safety concerns.
- Maintain
records of referrals and interventions to enable monitoring and evaluation of
the service;
- To
provide patients with high quality, easy to understand information to assist
them in making choices about their care.
- To
take a holistic approach, based on the persons priorities, and the wider
determinants of health.
- To
assist patients to be better prepared to have conversations on shared decision
making and to improve awareness of shared decision making and related support
tools
- 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.
- 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.
- 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;
- Take
referrals for individuals or proactively identify people who could benefit from
support through care coordination;
- Explore
and assist people to access a personal health budget where appropriate.
- Identify
unpaid carers and help them access services to support them;
- 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;
- Record
and collate information according to agreed protocols and contribute to
evaluation reports required for the monitoring and quality improvement of the
service.
- Adhere
to organisational policies and procedures, including confidentiality,
safeguarding, lone working, information governance, equality diversity and
inclusion training and health and safety
- Work
with Team leader for advice and support.
- Act as a
champion for personalised care and shared decision making within the PCN
Key Result Areas
- Actively
collect and maintain data that will demonstrate patient improvement in key
areas.
- Ensure
delivery of best practice in clinical practice, caseload management, education,
research, and audit, to achieve Primary Care Network and local population
objectives.
- To
take an active role in risk assessment, supporting implementation of strategies
to minimise risk. Ensuring incidents and near misses are reported, through
promoting a no blame culture.
- Act
in accordance with GP Practice and Statutory Guidelines and Policies, including
Health and Safety initiatives.
- Will
work in accordance with Network priorities and objectives.
- Effectively manages own time, workload, and
resources.
Job description
Job responsibilities
Main
duties/Key tasks:
- Undertake
comprehensive geriatric assessment and/or annual review on all patients scoring
moderate to severe on the practice frailty register
- Keep
care records up to date by identifying and updating missing or out-of-date
information about the persons circumstances;
- Highlight
any safety concerns.
- Maintain
records of referrals and interventions to enable monitoring and evaluation of
the service;
- To
provide patients with high quality, easy to understand information to assist
them in making choices about their care.
- To
take a holistic approach, based on the persons priorities, and the wider
determinants of health.
- To
assist patients to be better prepared to have conversations on shared decision
making and to improve awareness of shared decision making and related support
tools
- 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.
- 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.
- 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;
- Take
referrals for individuals or proactively identify people who could benefit from
support through care coordination;
- Explore
and assist people to access a personal health budget where appropriate.
- Identify
unpaid carers and help them access services to support them;
- 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;
- Record
and collate information according to agreed protocols and contribute to
evaluation reports required for the monitoring and quality improvement of the
service.
- Adhere
to organisational policies and procedures, including confidentiality,
safeguarding, lone working, information governance, equality diversity and
inclusion training and health and safety
- Work
with Team leader for advice and support.
- Act as a
champion for personalised care and shared decision making within the PCN
Key Result Areas
- Actively
collect and maintain data that will demonstrate patient improvement in key
areas.
- Ensure
delivery of best practice in clinical practice, caseload management, education,
research, and audit, to achieve Primary Care Network and local population
objectives.
- To
take an active role in risk assessment, supporting implementation of strategies
to minimise risk. Ensuring incidents and near misses are reported, through
promoting a no blame culture.
- Act
in accordance with GP Practice and Statutory Guidelines and Policies, including
Health and Safety initiatives.
- Will
work in accordance with Network priorities and objectives.
- Effectively manages own time, workload, and
resources.
Person Specification
Knowledge
Essential
- Understanding of Information Governance and Confidentiality in the NHS
- Understanding of equality and diversity issues and how this affects patients, visitors and staff
- Understanding of what the NHS Constitution means to you, and your responsibilities to the public, patients and colleagues.
- Awareness of clinical governance
Qualifications
Essential
- Minimum GCSE (or equivalent) inc. Maths and English grade C;
- Driving license & use of a vehicle.
- Experience in working as a carer
- Experience of working in a health related sector
- Experience of multidisciplinary working
- Excellent IT skills
Desirable
- Dementia Awareness
- Chronic Disease management
- Level 3 Qualification in Health & Social Care
- Care certificate
- Experience in working as a Health Care Assistant in general practice
- Local knowledge of VCSE and community services in the locality
- Knowledge of how the NHS works, including primary care
Skills
Essential
- Ability to plan and manage own time effectively
- Ability to generate written communication which is relevant, concise, and accurate
- An ability to use information technology to maximise personal effectiveness, or willingness to develop these skills
- Ability to demonstrate verbal communication skills
Desirable
- Understanding of current changes within Primary Care, particularly those affecting Primary Care Networks
- Clinical use of Emis clinical system
Aptitude
Essential
- An ability to be flexible in a changing environment
- An ability to work independently
- An ability to demonstrate a commitment to team working
- An ability to learn and apply knowledge appropriately
- An ability to use tact and diplomacy when necessary
- Demonstrates innovative ideas
Desirable
- An ability to develop and maintain links with outside agencies
- Flexibility to learning
Attitude
Essential
- Care and respect for patients and their right to confidentiality.
- Punctual & reliable
- Positive, tolerant, empathetic team player
- Personal integrity and loyalty
Person Specification
Knowledge
Essential
- Understanding of Information Governance and Confidentiality in the NHS
- Understanding of equality and diversity issues and how this affects patients, visitors and staff
- Understanding of what the NHS Constitution means to you, and your responsibilities to the public, patients and colleagues.
- Awareness of clinical governance
Qualifications
Essential
- Minimum GCSE (or equivalent) inc. Maths and English grade C;
- Driving license & use of a vehicle.
- Experience in working as a carer
- Experience of working in a health related sector
- Experience of multidisciplinary working
- Excellent IT skills
Desirable
- Dementia Awareness
- Chronic Disease management
- Level 3 Qualification in Health & Social Care
- Care certificate
- Experience in working as a Health Care Assistant in general practice
- Local knowledge of VCSE and community services in the locality
- Knowledge of how the NHS works, including primary care
Skills
Essential
- Ability to plan and manage own time effectively
- Ability to generate written communication which is relevant, concise, and accurate
- An ability to use information technology to maximise personal effectiveness, or willingness to develop these skills
- Ability to demonstrate verbal communication skills
Desirable
- Understanding of current changes within Primary Care, particularly those affecting Primary Care Networks
- Clinical use of Emis clinical system
Aptitude
Essential
- An ability to be flexible in a changing environment
- An ability to work independently
- An ability to demonstrate a commitment to team working
- An ability to learn and apply knowledge appropriately
- An ability to use tact and diplomacy when necessary
- Demonstrates innovative ideas
Desirable
- An ability to develop and maintain links with outside agencies
- Flexibility to learning
Attitude
Essential
- Care and respect for patients and their right to confidentiality.
- Punctual & reliable
- Positive, tolerant, empathetic team player
- Personal integrity and loyalty
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.