Care Coordinator

Job responsibilities

Purpose of the role

Care coordinators play an important role 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.

Care coordinators review patients needs and help them access the services and support they require to understand and manage their own health and well-being, referring to social prescribing link workers, health and well-being coaches, and other professionals where appropriate.

Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.

The successful candidate will be based in a local cluster of General Practices as part of East Merton Primary Care Network. They 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 organizational 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.

This role is intended to become an integral part of the practices multidisciplinary team, working alongside social prescribing link workers and health and well-being coaches to provide an all-encompassing approach to personalized care and promoting and embedding the personalized care approach across the team. There may be a need to work remotely depending on the requirements of the role. Please note that the role of a care coordinator is not a clinical role.

Key responsibilities

• Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalized 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 well-being, 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 well-being 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 Practice to proactively identify and manage a caseload, which may include patients with long term health conditions, and where appropriate, refer to other health professionals.
• 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.
• 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.
• Delivery of personalized care
• Monitoring and evaluating patient progress.
• Communicating the needs of patients to medical staff
• Link between local community and the practice.
• Maintenance of good patients relationship
• Ensuring patients receives the best care.
• Logistically planning patient care
• Compliance
• Developing healthcare programs
• Maintaining accurate records
• Managing and coordinating patient care
• Scheduling of appointments
• Handling patient case management and education

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 well-being 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 practice 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 personalized care and support plans.
• Review and update personalized 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

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 well-being 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.

Qualifications

Essential

• NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
• Demonstrable commitment to professional and personal development
• is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute.
• Proficient in MS Office and web-based services

Experience

Essential

• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health and health improvement
• 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)

Desirable

• Experience of working within multiprofessional team environments
• Experience of supporting people, their families and carers in a related role
• Experience or training in personalised care and support planning
• Experience of data collection and using tools to measure the impact of services
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Skills and Knowledge

Essential

• 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 Safeguarding Children and Vulnerable Adults policies and processes
• 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
• Other Meets DBS reference standards and criminal record checks
• Ability to travel across the locality on a regular basis

Desirable

• Knowledge of how the NHS works, including primary care and PCNs
• 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
• Willingness to work flexible hours when required to meet work demands
• Access to own transport
• Proficient speaker of another language to aid communication with people in the community for whom English is a second language.

Personal Qualities and artibutes

Essential

• Ability to actively listen, empathise with people and provide personalised support in a non-judgmental way. (Essential)
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• (Essential)
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and
• stakeholders (Essential)
• 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 (Essential)
• Ability to maintain effective working relationships and to promote
• collaborative practice with all colleagues (Essential)
• Ability to demonstrate personal accountability, emotional resilience and
• work well under pressure (Essential)
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines (Essential)
• High level of written and verbal communication skills (Essential)
• Knowledge of, and ability to work to policies and procedures, including
• confidentiality, safeguarding, lone working, information governance, and health and safety (Essential)

Desirable

• Commitment to reducing health inequalities and proactively working to
• reach people from diverse communities (Desirable)
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential (Desirable)
• Ability to work from an asset-based approach, building on existing community and personal assets (Desirable)
• Ability to work flexibly and enthusiastically within a team or on own initiative (Desirable)
• Ability to provide motivational coaching to support peoples behavior change (Desirable)
• Ability to identify risk and assess / manage risk when working with
• individuals (Desirable)