Care Coordinator

Job description

Job responsibilities

Work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients.

Work closely and in partnership with the Social Prescribing Link Workers and others, supporting patients to utilise decision aids, access training, employment and appropriate benefits where eligible and help create single Personalised Care and Support Plans (PCSP), in line with best practice.

Help patients manage their needs through proactively responding to queries, making and managing appointments, other interventions that progress the patients care journey, holistically bringing together all of a persons identified care and support needs, and explore options to meet these within a single PCSP, based on what matters to the person.

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level, exploring and assisting people to access personal health budgets where appropriate.

Modify and adapt working practices to meet the needs of the patient, where appropriate, providing coordination and navigation through the aid of digital tools for patients and their carers across the health and care services.

Make appropriate use of equipment, technology (including software) which you are trained on, producing reports and other documentation as required, utilising the population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care

Raise awareness within the PCN of shared decision-making and of how to identify patients who may benefit from shared decision making; and support PCN staff and patients to be more prepared to have shared decision-making conversations.

Work as an effective member of a multi-professional team, giving support to staff as required, without assuming supervision, education or line management role.

Complete documentation (including electronic patient records where used) as per PCN guidelines and Information Governance (IG) requirements, e.g. Data Protection.

Support the production and implementation of new working processes within the practice to optimise the quality of patient care.

Support the overall effectiveness of exemplary coordination and delivery of the MDTs within the PCN.

Participate in continuing professional development, education, and training including statutory and mandatory training and keep up to date with evidence based knowledge and competence in all aspects of the role.

Have an awareness of groups of patients at high risk, which may include risks that are patient related, medicine related, or both, and know how to mitigate and reduce risks accordingly.

Proactively provide feedback to you manager when patient care and service provision is impacted by changes to the PCNs policies, either negative or positive, to support the continual development of the PCN.

Support the production of patient information leaflets and posters, providing advice and recommendations for projects and business change initiatives where appropriate, and ensuring that people have good quality written or verbal information to help them make choices about their care.

Represent the organisation positively and professionally, behaving as an ambassador for the PCN by displaying the organisations values and levels of expected professionalism at all times.

Effectively manage own time, workload and resources, maintaining confidentiality at all times.

Influence, motivate and involve individuals and teams to reach necessary performance target expectations.

Assist with any other duties to meet the needs of the practice and the service provided.

Person Specification

Experience

Essential

• Experience in dealing with a diverse range of people in a public/patient environment.
• Experience in demonstrating a good level of professionalism, responsibility and accountability.
• Demonstrable experience of being able to remain calm under pressure and showing empathy in stressful situations.
• Experience of partnership/collaborative working and of building relationships across a variety of organisations/
• Knowledge of IT systems, including ability to use word processing systems and software, emails, and the internet to create simple plans and reports.

Desirable

• Minimum of 1 years care coordination experience.
• Experience of coordination and development of a range of systems and processes in relevant organisational settings.
• Able to analyse and interpret care plans and needs assessments.
• Experience of working effectively within a multidisciplinary team.
• Awareness of systems to support the management of patients in a primary care setting.

Skills and Abilities

Essential

• Excellent communication skills, with the ability to select, adjust and use appropriate forms of verbal and non-verbal communication with patients and professional colleagues.
• Excellent interpersonal skills, with the ability to establish and maintain effective relationships with others.
• Able to appropriately build relationships to gain the cooperation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals).
• Able to communicate with patients, relatives, colleagues, other health professionals and stakeholders in a calm, caring and professional manner, treating them with dignity and respect at all times.
• Ability to assess a professional situation, determine the nature and severity of the problem and utilise knowledge and experience to deal with the problem.
• Excellent attention to accuracy and detail within administrative tasks.
• Can demonstrate a flexible approach to meet service needs and adapt to cope with uncertainty and change.
• Excellent time keeping skills and able to work effectively under pressure.
• Exceptional ability to effectively manage, plan and coordinate multiple activities, overcoming barriers and issues that would prevent seamless coordination of activities.
• Adaptable, self-motivated and able to work flexibly and enthusiastically as part of an integrated multi-skilled team, or on own initiative.
• Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary, and take accountability for own development needs.
• Commitment to reducing health inequalities and proactively working to reach people from all communities.
• Embraces equality, diversity and inclusivity at every opportunity and the NHS core principles; dignity and respect, compassion, be included, responsive care and support and wellbeing.
• Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance and health and safety.

Desirable

• Able to identify anxiety and stress in patients, carers, relatives and others, recognising the potential impact upon communication.
• Can demonstrate good influencing and negotiation skills, empathy and reassurance.
• Able to identify and raise risk management issues according to policy/protocol.
• Recognise that they are responsible for decisions made and recognises when to refer patient care to more suitable care providers.
• Recognises priorities when problem solving, identifying deviations from normal patterns, and is able to refer these where required for resolution.
• Can demonstrate the ability to work in a busy environment dealing with urgent and important tasks whilst also supporting others.

Qualifications

Essential

• Must have right to work in the UK
• A good general education.
• Evidence of continuing professional development.
• Demonstrates a continued commitment to improve skills and the ability to work in new areas.

Desirable

• Educated to diploma level, or equivalent experience,
• Safeguarding and other statutory and mandatory training.

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

Bexley Health Neighbourhood Care CIC

Address

Plas Meddyg Surgery

40 Parkhill Road

Bexley

Kent

DA51HU

Employer's website

https://www.bhnc.org.uk/ (Opens in a new tab)