Care Coordinator (Frailty Team)

Job description

Job responsibilities

Care Coordinators will:

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.

Be a first point of contact for those patients whose care you are supporting

Be a first point of contact for patients who have been referred via the suspected cancer referral pathway from primary care into secondary care. Ensuring cancer referral safety netting.

Be a point of contact for patients by letter, telephone, or face to face appointments to ensure the relevant supporting information and support is given to include the importance of their attendance at hospital appointments.

Be able to listen to a patients needs from the point of referral to newly diagnosed and beyond.

To be able to manage a patient needs appropriately documenting all consultations within the patients notes.

Work with patients, their families, and carers to provide support and care and manage their needs.

Listen to patients needs and help to manage their needs through answering queries and sign posting to the relevant services.

Contact and organise clinical reviews for all patients with a new diagnosis with a GP where appropriate.

Complete a Cancer care review with patients via telephone consultation or face to face where current COVID climate conditions permits, recording an accurate and concise consultation within the patients notes using the clinical systems.

Liaise with appropriate GPs and professionals when appropriate to maximise patient needs to include identifying patients to the Gold Standard Framework (GSF) list.

Build effective relationships with each practice and their staff.

Build effective relationships with local system partners such as: Cancer Alliances, Hospice Outreach team, District Nurses and Public Health.

To run weekly clinical system searches for newly diagnosed cancer patients, contacting patient to arrange appointments.

Contribute to increasing uptake of national screening programmes

Contribute to the evaluation of the service, collate, and input timely data and suggest/implement service improvements.

To produce performance and quality improvement reports as requested by PCN Leads.

Keeping up to date with National/Local Strategies.

Ability to work within a team and independently.

Attend and contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the service performance.

Work collaboratively with the current Clinical Leads, Clinical Pharmacists, Pharmacy Technicians, Care Coordinators and Social Prescriber Link Workers, through peer support and as part of the wider Team.

Work proactively with Acute Trusts to understand the discharge process and be able to positively input into processes that optimise the patients journey.

Undertake any other duties deemed appropriate by the practice or PCN Cancer Lead, practice Clinical Care Co-ordinator and practice Operational Manager.

Complete annual mandatory training as required.

Enrol as a member of the Personalised Care Institute to receive up to date training and opportunity to join webinars.

Participation in an annual individual performance review, including taking own responsibility for maintaining record of own personal record.

Referrals

Make appropriate referrals recording within the patient notes and complying with relevant data privacy and consent

Seek regular feedback about the quality of service and impact of care coordination on referral agencies.

Provide personalised support

Work with the patient, their families and carers and consider how they can all be supported by services available to them.

Bring together a persons identified care needs and explore their options to meet these within a simple coproduced personalised care and support plan, including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.

Seek advice and support from the Clinical Leads and/or identified individual(s) to discuss patient-related concerns (referring the patient back to the GP or other suitable health professional if required).

Data capture

Work sensitively with people, their families and carers to capture key information, enabling comprehensive and accurate records of support.

Encourage people, their families and carers to provide feedback and engage fully in the care coordination process.

Work closely within the MDT and with GP practices within the PCN to ensure that the comprehensive records of MDT case discussions are inputted into clinical systems, adhering to data protection legislation and data sharing agreements.

Other

Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.

Contribute to the development of policies and plans relating to equality, diversity and health inequalities.

Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.

Duties may vary from time to time without changing the general character of the post or the level of responsibility.

Person Specification

Qualifications

Essential

• GCSE grade A to C in English or Maths or equivalent level
• Willing to engage with the training programmes via the Personalised Care Institute for the new roles identified within primary care networks as part of the NHS Long Term Plan

Desirable

• NVQ Qualification in Health and Social Care or equivalent or working towards a qualification
• Member of the Personalised Care Institute in order to complete Personalised Care training
• Attendance at courses/qualifications gained in Cancer

Experience

Essential

• Minimum 2 years customer service experience

Desirable

• Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
• Experience of working in a primary care setting
• Experience of working or volunteering in a healthcare or care sector setting
• Experience of using tools to create individualised plans
• Experience of organising recurring events or meetings

Knowledge & Skills

Essential

• To effectively communicate with different groups and individuals in various situations
• To be able to form good working relationships with people from a wide range of social, cultural, and ethnic backgrounds
• Strong IT skills, including Microsoft Office. Ideally you will have used a clinical software system such as EMIS Web.
• Ability to work as a team member and autonomously
• Effective time management (planning and organising)
• Ability to listen, empathise with people and provide person centered support in a non-judgmental way
• Ability to use own initiative, discretion, and sensitivity
• Problem solving and analytical skills
• Ability to follow policy and procedure

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

Hall Street Medical Centre

Address

103 Crab Street

St. Helens

Merseyside

WA10 2DJ

Employer's website

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