Job summary
Care
coordinators play an important role within the Practice 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.
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 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.
Main duties of the job
Undertake
comprehensive geriatric assessment and/or annual review on all patients scoring
moderate to severe on the practice frailty register.
Working with other members of the frailty team to plan and visit patients on a proactive or reactive need, working in patients own homes and care settings.
Working with Patients in Care Homes, anticipatory care planning and supporting personalised care planning.
Advise patients on maintaining health and refer to allied services when needs are identified.
Maintain accurate, healthcare records appropriate to the consultation.
The role will cover reviews for different cohorts of patients, including long term conditions, mental health and disabilities.
Highlight any safeguarding concerns.
Provide coordination and navigation for people and their carers across health and care services.
Explore and assist people to access personal health budget where appropriate.
About us
Birbeck Medical Group covers a 10mile square radius of Penrith. Currently we have over 14500 patients. We are a forward thinking Practice and currently have over 50staff and offer an opportunity for the successful candidate to broaden his/her clinical experience.
We offer team working which is fully supported by clinical and non-clinical staff working together for the benefit of our patients.
Job description
Job responsibilities
Keep
care records up to date by identifying and updating missing or out-of-date
information about the persons circumstances
Highlight
any safety concerns. (Safeguarding)
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 Practice
Job description
Job responsibilities
Keep
care records up to date by identifying and updating missing or out-of-date
information about the persons circumstances
Highlight
any safety concerns. (Safeguarding)
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 Practice
Person Specification
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
Experience
Essential
- Experience of working in a health related sector
- Experience of multidisciplinary working
- Excellent IT skills
Desirable
- 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
Person Specification
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
Experience
Essential
- Experience of working in a health related sector
- Experience of multidisciplinary working
- Excellent IT skills
Desirable
- 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
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.