Job summary
This is an exciting opportunity for a Care Coordinator to join the South Crawley PCN.
This role is to support the smooth co-ordination of patient care across the South Crawley Primary Care Network for the benefit of our patients. This role is advertised to work across Saxonbrook Medical Centre, Gossops Green Medical Centre, Coachmans Medical Practise and Bewbush Medical Centre.
Full time / Part time considered.
This post is until 31st March 2024.
Main duties of the job
The Care Coordinator will be responsible for consulting with patients and determining their needs, developing care plans, coordinating patient-care services, educating them about their condition, empowering them to be independent whenever possible and working with the care team to evaluate interventions.
The post holder will support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence.
The post holder will talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patients home if needed.
Please see full Job Description for more information on the role.
About us
Alliance for Better Care is a not-for-profit organisation that is proud to support the sustainability and success of General Practice in East Surrey, Crawley, Horsham and Mid-Sussex. Our strategy is to support Primary Care Networks and individual practices through management expertise, at-scale clinical services and back-office functions, as we believe that General Practice is fundamental to improving the health and happiness of our communities.
ABC provide employment and management support to South Crawley Care Primary Care Network comprising the following practices:
- Saxonbrook Medical Centre
- Gossops Green Medical Centre
- Coachmans Medical Practise
- Bewbush Medical Centre
Job description
Job responsibilities
A few responsibilities:
MDT Coordination
- Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting.
- Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions.
Managing a caseload
- Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence.
- Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions.
- Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacists, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews.
- With the help of relevant clinical colleagues, develop a care plan to address patients personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare.
- Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
- Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans.
- Check in on the patient regularly and evaluate and document their progress.
Please see full Job Description for further information on the role.
Job description
Job responsibilities
A few responsibilities:
MDT Coordination
- Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting.
- Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions.
Managing a caseload
- Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence.
- Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions.
- Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacists, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews.
- With the help of relevant clinical colleagues, develop a care plan to address patients personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare.
- Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
- Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans.
- Check in on the patient regularly and evaluate and document their progress.
Please see full Job Description for further information on the role.
Person Specification
Experience
Desirable
- Experience of working directly in either the NHS or Adult Social Care.
Personal Qualities and Attributes
Essential
- Able to listen, empathise with people and provide person centred support in a non-judgemental way.
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Committed to reducing health inequalities and proactively working to reach people from all communities.
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Able to identify risk and assess/manage risk when working with individuals.
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.
- Able to provide leadership and to finish work tasks.
- Able to maintain effective working relationships and to promote collaborative practice with all colleagues.
- Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues.
- Demonstrates personal accountability, emotional resilience and works well under pressure.
- Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
- High level of written and oral communication skills.
- Able to work flexibly and enthusiastically within a team or on own initiative.
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
Desirable
- Excellent IT skills including Excel and knowledge of GP clinical systems.
Qualifications
Essential
- Demonstrable commitment to professional and personal development.
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards.
- Training in motivational coaching and interviewing or equivalent experience.
Person Specification
Experience
Desirable
- Experience of working directly in either the NHS or Adult Social Care.
Personal Qualities and Attributes
Essential
- Able to listen, empathise with people and provide person centred support in a non-judgemental way.
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Committed to reducing health inequalities and proactively working to reach people from all communities.
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Able to identify risk and assess/manage risk when working with individuals.
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.
- Able to provide leadership and to finish work tasks.
- Able to maintain effective working relationships and to promote collaborative practice with all colleagues.
- Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues.
- Demonstrates personal accountability, emotional resilience and works well under pressure.
- Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
- High level of written and oral communication skills.
- Able to work flexibly and enthusiastically within a team or on own initiative.
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
Desirable
- Excellent IT skills including Excel and knowledge of GP clinical systems.
Qualifications
Essential
- Demonstrable commitment to professional and personal development.
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards.
- Training in motivational coaching and interviewing or equivalent experience.
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.
