Care Coordinator - West of Waverley PCN

Job description

Job responsibilities

Job responsibilities

Support our Population Health Management approach

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.

Support the coordination and delivery of Multidisciplinary Teams (MDTs) within the PCN under the Anticipatory Care, Palliative Care & respect framework and also assist the GPs co-ordinating with the Traveller Community.

Support the development of other services under the Network Contract Directed Enhanced Service, including the management of Long-Term Conditions through the facilitation of remote monitoring.

Support patients

Support patients to utilise decision aids in preparation for a shared decision-making conversation. Holistically bring together all of a persons identified care and support needs and explore options to meet these within a single personalised care and support plan, in line with best practice, based on what matters to the person.

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. Using tools to understand peoples level of knowledge and confidence skills in managing their own health.

Support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to Social Prescribing Link Workers. Assist people to access self-management education courses, peer support or interventions that support them to take more control of 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, working closely with Social Prescribing Link Workers, Health and Wellbeing Coaches, and other primary care professionals.

Support PCN development

Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them.

Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN. Support the transition of patients between primary, secondary and community care services, supporting health and care professionals and their patients/clients navigate the system.

Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register.

Raise awareness within the PCN of shared decision-making and decision support tools.

Raise awareness 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.

Professional development

Work with a named clinical point of contact for advice and support.

Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required. The post holder would need to undertake appropriate training as set out by the Personalised Care Institute as part of their personal development plan which the PCN would support in terms of funding and time.

Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.

Please see attached job description for further information.

Please note, the employer will be Chiddingfold Surgery.

Person Specification

Experience

Essential

• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience of working within multi-professional team environments
• Experience of supporting people, their families and carers in a related role
• Experience or training in personalised care and support planning
• Experience of data collection and using tools to measure the impact of services

Desirable

• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Knowledge and Understanding

Essential

• Knowledge of how the NHS works, including primary care and PCNs
• Knowledge of the personalised care approach
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• An understanding of health inequalities and a commitment to reducing them and proactively working to reach people from diverse communities
• Ability to recognise and work within limits of competence and seek advice when needed, to have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, and when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
• Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social

Desirable

• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes

Other

Essential

• Meets DBS reference standards
• Willingness to work flexible hours when required to meet work demands
• Able to work across several sites and travel to meet with stakeholders

Desirable

• Holds a full, current UK driving licence

Skills and Competencies

Essential

• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
• Ability to identify risk and assess / manage risk when working with individuals
• Ability to work from an asset-based approach, building on existing community and personal assets
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• High level of written and verbal communication skills
• Computer literate with a sound knowledge of Microsoft Office

Attributes

Essential

• Demonstrate personal accountability, emotional resilience and work well under pressure
• Organised, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• Personable and approachable, caring and sympathetic
• Self-confident and able to work with minimum direction
• Adaptable and innovative
• Enthusiasm, energy and drive
• Trustworthy, discrete, honest and reliable
• Determined and willing to persevere

Qualifications

Essential

• Evidence of a sound general education (GCSEs or equivalent) to include English and Maths grade C or above

Desirable

• NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards.

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

Procare Health Limited

Address

The Surgery

Ridgley Road

Chiddingfold

Godalming

Surrey

GU84QP

Employer's website

https://www.procarehealth.co.uk/ (Opens in a new tab)