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 for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.

Person Specification

Qualifications

Essential

• The Personalised Care Institute will set out what training is available and expected for Care Co-ordinators.
• Active and empathic listening.
• Effective questioning.
• Building trust and rapport.
• Shared agenda setting.
• Collaborative goal setting.
• Shared follow up planning.
• Using simple health literate communication techniques such as teach-back.
• Structuring conversations using a coaching approach.
• Knowledge of the core concepts and principles of personalised care, shared decision making, patient activation, health behaviour change, self-efficacy, motivation and assets-based approaches.

Desirable

• On-going Development
• Refresher sessions
• Buddying with peers
• One-to-one support from a practitioner with health coaching experience
• Action Learning Sets
• E-learning to revisit or deepen training
• Supervision

Skills, Competencies, On-going development

Essential

• Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids.
• Bring together a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with person centred service plan (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 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 (patient 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.
• Support the coordination and delivery of MDTs within PCNs

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

Castlegate & Derwent Surgery

Address

Cockermouth Health Centre

Isle Road

Cockermouth

Cumbria

CA13 9HT

Employer's website

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