Job summary
This post is offered to support existing Practice Care Coordinator colleagues in Colsterworth Medical Practice, Glenside Country Practice and Market Cross Surgery to increase capacity to support people in their own homes and within care home settings.
The role will be employed within K2 Healthcare and based within the Grantham Neighbourhood Hub, hours of work to be negotiated at interview, but full and part time options will be considered.
Main duties of the job
- The role of the Practice Care Co-ordinator is to support both
the practice staff and members of the Neighbourhood Team to identify and
support people to reduce the risk of unplanned hospital admissions and to
effectively support those individuals in the community.
- To work dedicated hours to focus on proactively case managing
people and being the preferred point of contact for the patient and
Neighbourhood Team to achieve the following objectives:
- To be a pro-active member of the
Integrated Neighbourhood Team and Southwest Primary Care Networks.
- To pro-actively engage with people
deemed to be at risk of hospital admission or health deterioration.
- To proactively engage with frequent
fliers those attending A&E and utilising OOH services.
- To pro-actively engage with Home
First Teams to reduce length of stay in acute hospital settings.
- To pro-actively engage with people
living in care home settings.
- To be the key contact within the GP
Practice environment.
About us
K2 Healthcare is a GP federation constituted of 16 member GP Practices in South West Lincolnshire with two Primary Care Networks and supporting a population of 133,000 people.
K2 works together to share resources and expertise that enable practices to provide shared services and business systems to provide the best possible care for our population, ensure sustainability, growth and value for GP practices and system partners within available resources.
The Better Lives Lincolnshire Integrated Care System sees us working in a provider collaborative with the Primary Care Network Alliance, Secondary Care, Community Health, Mental Health, Social Care as well as Local Authorities, and the Community and Voluntary Sector.
How we do it is as important as what we do and relationships with our partners is at the core of everything we do.
Neighbourhood Working describes an integrated approach to managing patients, through a blended workforce that encompasses both health and social care; to include acute, voluntary and community sectors where barriers to working are negated, the health and wellbeing needs of the individual are at the centre of decision-making, care is proactive and not reactive, and services are provided in a timely manner.
Job description
Job responsibilities
ROLE SUMMARY
Neighbourhood Working is a new way of strengthening and
redesigning community services for a local population. It empowers people and
communities to take an active role in their health and wellbeing, with greater
choice and control over the care they need. It also supports the improvement,
integration, and personalisation of services in Lincolnshire.
CORE NEIGHBOURHOOD WORKING PRINCIPLES
- Having a different conversation
- Delivering Home First principles
- Enabling self-care and peer support
- Recognising whats important to me
- Collective accountability
- Positive risk taking
- Assessing immediate needs and addressing barriers to
improve quality of life
- To liaise with the registered GP and other practice based
staff in addition to all other providers and services utilising, where
appropriate, utilising a multi-disciplinary approach.
- To implement and review individual care plans,
self-management plans in liaison with the GP practice team. To include advanced
care plans, Respect documents, personalised care and support plans
- Plan and monitor those on GP caseloads and directed by the
practice team or identified by the wider Neighbourhood Team at risk of
deterioration.
- Provide enhanced support to Nursing and Residential homes
with a focus on strengthening relationships and improving access through
information sharing, education, and advice.
-
To ensure all people
in Nursing and Residential homes have care plans including advanced care plans,
Respect documents, personalised care, and support plans and to provide a
holistic review of all people in these homes with updates of their plans.
KEY RESPONSIBILITIES
- Act as a point of contact between the GP Practice Team,
Neighbourhood Team, people and their carers.
- Develop and maintain a detailed knowledge of local services
to enable supported signposting of people with identified need, sharing
information with the Neighbourhood Team/Primary Care Network.
- Liaise with GPs and practice teams to identify people who are
elderly, frail or who have long term health need and support.
- Support the early identification of those with life limiting
conditions including those with palliative and end of life symptoms and
conditions in order that they are supported to achieve a good end of life
experience.
- Liaise with primary, secondary and specialist care services
as required.
-
Work with
Neighbourhood Team colleagues to help identify people at risk of loss of
independence or admission to hospital as a result of inadequate social support.
- Provide these cohorts of people signposting to identified
services to maintain their independence and improve their health and
well-being.
- Visit people in community, home, or care home settings to
assess and discuss their care needs involving carers as appropriate.
- Implement personal care plans for individual people, ensuring
preventative actions are detailed to support the appropriate use of services.
- Communicate the care plan to the GP and any other members of
the Neighbourhood Team involved in the persons care and upload to the relevant
records.
- Ensure that identified people receive the right level of help
at the right time and help them to experience a joined-up service by liaising
with relevant members of the Neighbourhood Team.
- Work with patient, carers and the Neighbourhood Team to
encourage the patient to adopt effective self-management and self-help seeking
approaches to reduce unnecessary hospital admissions.
- Liaise with other agencies to ensure timely and appropriate
engagement as required.
- Support people to access community care assessments as well
as carers assessments.
- Where
a personal healthcare budget is allocated provide advice as required regarding
the key choices the patient will need to make.
- Identify unpaid carers and direct them to access services as
appropriate to provide them with support.
- Identify when urgent action or a step up in care is required
and promptly alert the relevant member of the Neighbourhood Team, highlighting
any safety concerns.
- Follow up on communications from out of hospital and
in-patient services regarding changes in condition of people to support the
practice to respond proactively to potentially unmet needs.
- Undertake visits or telephone contact to manage people on the
PCCs case load following any unplanned hospital admissions where appropriate.
- Participate in Practice multi-disciplinary meetings to
discuss people actively being managed by the Neighbourhood Team and any other
people from the PCCs case load needing discussion.
- To attend Neighbourhood Team MDT meetings plus any other
meetings. Updates between meetings to be shared with the Neighbourhood Team
colleagues.
- Maintain accurate and up to date records of patient contacts
using GP record systems and other IM&T systems relevant to the role i.e.
entering notes onto SystmOne using agreed read codes.
- To run regular patient searches using SystmOne to have an
up-to-date record of progress of achievement of Key Performance Indicators in
line with practice based recording and reporting requirements. Support the
Practice Managers in providing KPI reports for submission as requested.
- Work with K2
Federation Southwest Primary Care Networks, Neighbourhood Team and other agencies
to support and further develop this role.
KEY WORKING RELATIONSHIPS
- Practice teams
- Neighbourhood Team
- Care Homes
- Community
health services
- Mental Health and Learning Disability Services
- Specialist teams heart failure, diabetes etc.
- Specialist nursing services e.g. St Barnabas
- Hospital teams including ward, A&E, discharge and AIR
teams
- Safeguarding agencies
- Pharmacists
- Integrated Care Board
- Adult Social Care
- Social Prescribing Teams
- Voluntary Services
- Independent Care Homes
- Local Authority teams
- Housing Providers
- Independent living teams
Job description
Job responsibilities
ROLE SUMMARY
Neighbourhood Working is a new way of strengthening and
redesigning community services for a local population. It empowers people and
communities to take an active role in their health and wellbeing, with greater
choice and control over the care they need. It also supports the improvement,
integration, and personalisation of services in Lincolnshire.
CORE NEIGHBOURHOOD WORKING PRINCIPLES
- Having a different conversation
- Delivering Home First principles
- Enabling self-care and peer support
- Recognising whats important to me
- Collective accountability
- Positive risk taking
- Assessing immediate needs and addressing barriers to
improve quality of life
- To liaise with the registered GP and other practice based
staff in addition to all other providers and services utilising, where
appropriate, utilising a multi-disciplinary approach.
- To implement and review individual care plans,
self-management plans in liaison with the GP practice team. To include advanced
care plans, Respect documents, personalised care and support plans
- Plan and monitor those on GP caseloads and directed by the
practice team or identified by the wider Neighbourhood Team at risk of
deterioration.
- Provide enhanced support to Nursing and Residential homes
with a focus on strengthening relationships and improving access through
information sharing, education, and advice.
-
To ensure all people
in Nursing and Residential homes have care plans including advanced care plans,
Respect documents, personalised care, and support plans and to provide a
holistic review of all people in these homes with updates of their plans.
KEY RESPONSIBILITIES
- Act as a point of contact between the GP Practice Team,
Neighbourhood Team, people and their carers.
- Develop and maintain a detailed knowledge of local services
to enable supported signposting of people with identified need, sharing
information with the Neighbourhood Team/Primary Care Network.
- Liaise with GPs and practice teams to identify people who are
elderly, frail or who have long term health need and support.
- Support the early identification of those with life limiting
conditions including those with palliative and end of life symptoms and
conditions in order that they are supported to achieve a good end of life
experience.
- Liaise with primary, secondary and specialist care services
as required.
-
Work with
Neighbourhood Team colleagues to help identify people at risk of loss of
independence or admission to hospital as a result of inadequate social support.
- Provide these cohorts of people signposting to identified
services to maintain their independence and improve their health and
well-being.
- Visit people in community, home, or care home settings to
assess and discuss their care needs involving carers as appropriate.
- Implement personal care plans for individual people, ensuring
preventative actions are detailed to support the appropriate use of services.
- Communicate the care plan to the GP and any other members of
the Neighbourhood Team involved in the persons care and upload to the relevant
records.
- Ensure that identified people receive the right level of help
at the right time and help them to experience a joined-up service by liaising
with relevant members of the Neighbourhood Team.
- Work with patient, carers and the Neighbourhood Team to
encourage the patient to adopt effective self-management and self-help seeking
approaches to reduce unnecessary hospital admissions.
- Liaise with other agencies to ensure timely and appropriate
engagement as required.
- Support people to access community care assessments as well
as carers assessments.
- Where
a personal healthcare budget is allocated provide advice as required regarding
the key choices the patient will need to make.
- Identify unpaid carers and direct them to access services as
appropriate to provide them with support.
- Identify when urgent action or a step up in care is required
and promptly alert the relevant member of the Neighbourhood Team, highlighting
any safety concerns.
- Follow up on communications from out of hospital and
in-patient services regarding changes in condition of people to support the
practice to respond proactively to potentially unmet needs.
- Undertake visits or telephone contact to manage people on the
PCCs case load following any unplanned hospital admissions where appropriate.
- Participate in Practice multi-disciplinary meetings to
discuss people actively being managed by the Neighbourhood Team and any other
people from the PCCs case load needing discussion.
- To attend Neighbourhood Team MDT meetings plus any other
meetings. Updates between meetings to be shared with the Neighbourhood Team
colleagues.
- Maintain accurate and up to date records of patient contacts
using GP record systems and other IM&T systems relevant to the role i.e.
entering notes onto SystmOne using agreed read codes.
- To run regular patient searches using SystmOne to have an
up-to-date record of progress of achievement of Key Performance Indicators in
line with practice based recording and reporting requirements. Support the
Practice Managers in providing KPI reports for submission as requested.
- Work with K2
Federation Southwest Primary Care Networks, Neighbourhood Team and other agencies
to support and further develop this role.
KEY WORKING RELATIONSHIPS
- Practice teams
- Neighbourhood Team
- Care Homes
- Community
health services
- Mental Health and Learning Disability Services
- Specialist teams heart failure, diabetes etc.
- Specialist nursing services e.g. St Barnabas
- Hospital teams including ward, A&E, discharge and AIR
teams
- Safeguarding agencies
- Pharmacists
- Integrated Care Board
- Adult Social Care
- Social Prescribing Teams
- Voluntary Services
- Independent Care Homes
- Local Authority teams
- Housing Providers
- Independent living teams
Person Specification
Aptitude
Essential
- Ability to effectively organise own workload and that of others with minimum supervision
- Ability to achieve goals with deadlines.
- Ability to work autonomously as well as within a team
- Ability to make decisions under pressure
- Ability to work sensitively to maintain high levels of diplomacy and confidentiality
- Enthusiasm, drive and the ability to cope in challenging situations
- Demonstrated capability to plan over short, medium and long-term timeframes and adjust plans and resource requirements accordingly
- Experience of setting up and implementing internal processes and procedures
- Ability to prepare and produce concise yet insightful communications for dissemination to senior stakeholders and a broad range of stakeholders as required
- Excellent communication skills, listening, written and verbal.
- Negotiation and conflict management skills and the ability to influence in formal settings
- Demonstrated capabilities to manage own
Qualifications
Essential
- Registered Health or Care Professional
- Post graduate study in health-related studies relevant to long term conditions or equivalent experience
- Evidence of continuing professional development
- Post registration teaching qualification or willingness to undertake
Desirable
- Specialist interest qualification in health or care.
- Presentation skills and experience.
Skills and Knowledge
Essential
- Excellent communication skills, listening, written and verbal.
- Good organisational and planning skills.
- Excellent prioritisation skills and ability to work to tight deadlines.
- Skilled and sensitive communicator, confident in dealing with staff, people and service users
- Ability to deal with complex facts/situations, requiring analysis, interpretation and comparison of a range of options.
- IT skills including Good working knowledge and application of Microsoft Office packages
- Understand the wider determinants of health
Experience
Essential
- Experience of dealing with people with long term conditions.
- Evidence of ability to work autonomously.
- Evidence of working within a multidisciplinary team
- Evidence of teaching or mentorship
- Evidence of complex case management and multiagency working.
Person Specification
Aptitude
Essential
- Ability to effectively organise own workload and that of others with minimum supervision
- Ability to achieve goals with deadlines.
- Ability to work autonomously as well as within a team
- Ability to make decisions under pressure
- Ability to work sensitively to maintain high levels of diplomacy and confidentiality
- Enthusiasm, drive and the ability to cope in challenging situations
- Demonstrated capability to plan over short, medium and long-term timeframes and adjust plans and resource requirements accordingly
- Experience of setting up and implementing internal processes and procedures
- Ability to prepare and produce concise yet insightful communications for dissemination to senior stakeholders and a broad range of stakeholders as required
- Excellent communication skills, listening, written and verbal.
- Negotiation and conflict management skills and the ability to influence in formal settings
- Demonstrated capabilities to manage own
Qualifications
Essential
- Registered Health or Care Professional
- Post graduate study in health-related studies relevant to long term conditions or equivalent experience
- Evidence of continuing professional development
- Post registration teaching qualification or willingness to undertake
Desirable
- Specialist interest qualification in health or care.
- Presentation skills and experience.
Skills and Knowledge
Essential
- Excellent communication skills, listening, written and verbal.
- Good organisational and planning skills.
- Excellent prioritisation skills and ability to work to tight deadlines.
- Skilled and sensitive communicator, confident in dealing with staff, people and service users
- Ability to deal with complex facts/situations, requiring analysis, interpretation and comparison of a range of options.
- IT skills including Good working knowledge and application of Microsoft Office packages
- Understand the wider determinants of health
Experience
Essential
- Experience of dealing with people with long term conditions.
- Evidence of ability to work autonomously.
- Evidence of working within a multidisciplinary team
- Evidence of teaching or mentorship
- Evidence of complex case management and multiagency working.
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
