Job summary
The Care Coordinators will work as part of a growing multi-disciplinary team within general practice, supporting patients from a number of practices in their Network. This role will give you will have the chance to shape the service and the role. You will be working with patients to help them understand their conditions and what matters to them, and match the support that is available locally to keep them happy and independent. This might involve working with clinicians looking after local Care Homes, organising PCN multi-disciplinary team meetings for clinical and non-clinical staff or working with a specific cohort of patients yourself perhaps frail elderly or a particular long term condition.
We are looking for a positive team player who strives to go the extra mile to help out colleagues and others who come into contact with the organisation. You really want to make a difference! We need someone who can build strong relationships with team members and is committed to meeting deadlines.
The role will require high standards and great attention to detail, in order to provide an excellent service to patients and colleagues.
Main duties of the job
As a Care Coordinator, you will:
Proactively identify and support individuals, including the frail, elderly, and those with long-term conditions.
Coordinate and navigate care and support across health and care services, with a focus on vulnerable housebound patients and enhanced health in care homes.
Collaborate with clinical and non-clinical teams to ensure people receive the support they need.
Empower patients to manage their conditions and access necessary services, enhancing their quality of life.
Work alongside social prescribing link workers for a comprehensive approach to personalized care.
Engage with diverse populations from various cultural and social backgrounds.
Care co-ordinators are highly motivated, forward-thinking, and experienced individuals who are:
Excellent communicators with strong interpersonal skills.
Organised, patient, and empathetic.
Experienced in health, social care, or support roles involving direct contact with people, families, or carers.
About us
2 sites in County Durham
We have a well -established partnership with 8 GP partners working alongside 6 salaried GPs, 4 Nurse Practitioners (who also do home visits) and full nursing and support team
We have in-house pharmacists which greatly reduces our admin work
We have PCN ARRS roles including social prescribers, mental health workers and physios
We teach medical students and F2 doctors and are a training practice
We have developed GPSI services in dermatology, minor surgery and ENT and run these services from our practice
Job description
Job responsibilities
a.
To
work closely with practice and PCN healthcare roles, the CARE COORDINATOR is to
identify and work with a cohort of people to support their personalised care
requirements, including patients discharged from health or social care settings
to ensure any follow up actions are included and considered as part of the
patients personalised care plan, using any available decision support tools, templates
and software
b.
Collate
patients identified and support needs into a single personalised care and
support plan
c.
To
use primary care software to coordinate recall lists for patients who are being
monitored for chronic health conditions.
This is a vital role in ensuring patients receive their annual review.
d.
To
work with the PCN to proactively case find using population health intelligence
data
e.
To
help people to manage their needs by answering their queries and supporting
them in making appointments and ensuring patients have good quality written or
verbal information to help them make choices about their care.
f.
To
monitor all referrals, missed appointments, investigations, this will include
cancer 2ww referrals and missed follow up appointments.
g.
To
record patient's demographic and simple health information as part of their
personalised care plan/record.
h.
Work
closely with other social and health care professionals
i.
To
signpost patients to SPLW to access appropriate benefits where eligible as well
as taking up employment and training
j.
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
k.
To
provide patients with high quality, easy to understand information to assist
them in making choices about their care
l.
To
liaise with other CARE COORDINATORs in other practices within the PCN and share
best practice
m.
To
assist patients to access self-management education courses, peer support or
interventions that support them in their health and well-being
n.
To
provide coordination and navigation of patients, and where appropriate their
carers, across health and social care services, where appropriate working hand
in hand with social prescribing link workers (SPLW) and cancer care
coordinators
o.
To
support in the delivery of enhanced services and other service requirements on
behalf of the PCN
p.
To
attend and participate in the delivery of multi-disciplinary teams (MDT) within
PCNs.
q.
To
undertake all mandatory training and induction programmes
r.
To
contribute to and embrace the spectrum of clinical governance
s.
To
develop yourself and the role through participation in training and service
redesign activities
t.
To
attend a formal appraisal with their manager at least every 12 months. Once a
performance/training objective has been set, progress will be reviewed on a
regular basis so that new objectives can be agreed.
u.
To
contribute to public health campaigns (e.g. flu/covid clinics) through advice
or direct care
v.
To
maintain a clean, tidy, effective working area at all times
Job description
Job responsibilities
a.
To
work closely with practice and PCN healthcare roles, the CARE COORDINATOR is to
identify and work with a cohort of people to support their personalised care
requirements, including patients discharged from health or social care settings
to ensure any follow up actions are included and considered as part of the
patients personalised care plan, using any available decision support tools, templates
and software
b.
Collate
patients identified and support needs into a single personalised care and
support plan
c.
To
use primary care software to coordinate recall lists for patients who are being
monitored for chronic health conditions.
This is a vital role in ensuring patients receive their annual review.
d.
To
work with the PCN to proactively case find using population health intelligence
data
e.
To
help people to manage their needs by answering their queries and supporting
them in making appointments and ensuring patients have good quality written or
verbal information to help them make choices about their care.
f.
To
monitor all referrals, missed appointments, investigations, this will include
cancer 2ww referrals and missed follow up appointments.
g.
To
record patient's demographic and simple health information as part of their
personalised care plan/record.
h.
Work
closely with other social and health care professionals
i.
To
signpost patients to SPLW to access appropriate benefits where eligible as well
as taking up employment and training
j.
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
k.
To
provide patients with high quality, easy to understand information to assist
them in making choices about their care
l.
To
liaise with other CARE COORDINATORs in other practices within the PCN and share
best practice
m.
To
assist patients to access self-management education courses, peer support or
interventions that support them in their health and well-being
n.
To
provide coordination and navigation of patients, and where appropriate their
carers, across health and social care services, where appropriate working hand
in hand with social prescribing link workers (SPLW) and cancer care
coordinators
o.
To
support in the delivery of enhanced services and other service requirements on
behalf of the PCN
p.
To
attend and participate in the delivery of multi-disciplinary teams (MDT) within
PCNs.
q.
To
undertake all mandatory training and induction programmes
r.
To
contribute to and embrace the spectrum of clinical governance
s.
To
develop yourself and the role through participation in training and service
redesign activities
t.
To
attend a formal appraisal with their manager at least every 12 months. Once a
performance/training objective has been set, progress will be reviewed on a
regular basis so that new objectives can be agreed.
u.
To
contribute to public health campaigns (e.g. flu/covid clinics) through advice
or direct care
v.
To
maintain a clean, tidy, effective working area at all times
Person Specification
Experience
Essential
- Demonstrate an appreciation of the health needs of the patient population within the PCN
Desirable
- Experience of working in primary care
- Experience of working in a GP practice
- Knowledge of the geographical area within the PCN
- Understanding of safeguarding principles
- Knowledge of local health and social care provision
- Experience of dealing with vulnerable or elderly patients
Qualifications
Essential
- GCSE Grade A-C in Maths and English or skills level 2 Maths & English or equivalent
Desirable
- Qualification in a health or social care allied profession
Person Specification
Experience
Essential
- Demonstrate an appreciation of the health needs of the patient population within the PCN
Desirable
- Experience of working in primary care
- Experience of working in a GP practice
- Knowledge of the geographical area within the PCN
- Understanding of safeguarding principles
- Knowledge of local health and social care provision
- Experience of dealing with vulnerable or elderly patients
Qualifications
Essential
- GCSE Grade A-C in Maths and English or skills level 2 Maths & English or equivalent
Desirable
- Qualification in a health or social care allied profession
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.