Job summary
An exciting opportunity has arisen for a Care Co-ordinator to develop a pioneering role within primary care. The role will provide co-ordination and navigation for people and their carers across health and care services. This role mainly focusses on working as a part of our Enhanced Care Home Scheme
Care
Co-Ordinators provide extra time, capacity and expertise to support patients
in preparing for or in following up clinical conversations that they have with
primary care professionals i.e. doctors, nurses, physiotherapists, physician
associates, paramedics etc. They provide co-ordination and navigation for
people and their carers across in a variety of settings, including care homes
where they will work with the Enhanced Care Home Scheme Team to proactively
manage this cohort of patients.
The post holder will work closely with social
prescribing link workers, health and wellbeing coaches and other primary care
roles. Their focus is on delivering a
comprehensive model for personalised care, reflecting local priorities, health
inequalities and population health management risk stratification. They also support the coordination and
delivery of MDTs within PCNs.
Main duties of the job
The
role is varied, and may include supporting self-management education, peer
support, case management and facilitating group consultations, as well as liaising
with external stakeholders and
professionals across Primary Care & Social Care, arranging, coordinating
and attending MDTs.
You
will take an approach that is non-judgmental, based on strong communication and
negotiation skills. You will support personal choice and positive risk taking,
while ensuring that patients understand the accountability of their own actions
and decisions. Your role and skills will support and encourage the prevention
of developing further illness, or the deterioration of existing long-term
conditions.
When
working with our local care homes, the role will focus on undertaking a
personal care and support plan for each resident and sign posting patient needs
to fellow Enhanced Care Home Scheme Team members. Ensuring
seamless service provision significantly decreases the risk of the patient
deteriorating and thereby reduces the overall cost of care and the likelihood
that additional interventions will be needed in future.
About us
Employment will be with OWLS CIC Ltd West Lancashire GP
Federation, as a central function to the GP Practices and Primary Care Network
(PCN) members.
OWLS CIC is a small GP owned and led not-for-profit primary care
organisation, run by GPs and health professionals.
OWLS was founded in the 90s by a small group of General
Practitioners, with the main aim of ensuring high quality out of hours
services. In 2017 it transitioned to become a GP Federation to support and
provide services for its practices and to offer a vehicle that local GPs had an
opportunity to bid for, and provide, innovative primary care services in their
local area. We are a not-for-profit organisation, which means that all the
money we generate through service contracts is invested back into providing
patient care.
Job description
Job responsibilities
Care Co-Ordinators will:
Work closely
with practice and PCN healthcare roles, the PCC is to identify and work with a
cohort of people to support their personalised care requirements, using any
available decision support tools such as Patient Activation Measure (PAM),
templates and software
Meet patients, patient
carers and family members to discuss their personalised care requirements, the
services available to them and the help they want
Visit patients, checking
on the care that they have received and documenting it accordingly
Work with the care team
to evaluate interventions and identify where and when further ones will be
required
Help people
to manage their needs by answering their queries and supporting them in making
appointments
Support
people to access appropriate benefits where eligible as well as taking up
employment and training
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
Provide
patients with high quality, easy to understand information to assist them in
making choices about their care
Support
patients in understanding their level of knowledge, skills and confidence
(known as activation level) when participating in their health and well-being
using, where appropriate, the PAM
Liaise with
other PCCs in other practices across the region and share best practice
Assist
patients to access self-management education courses, peer support or
interventions that support them in their health and well-being
Where
appropriate, to assist patients to access personal health budgets
Provide coordination
and navigation of patients, and where appropriate their carers, across health
and social care services, where appropriate working hand in hand with social
prescribing link workers (SPLW)
Support in
the delivery of enhanced services and other service requirements on behalf of
the PCN
Lead in the
management of patient complaints and participate in the identification of any
necessary learning brought about through clinical incidents and near-miss
events
Actively participate in the delivery of multi-disciplinary
team (MDT) meetings within PCNs; responsible for preparatory admin, sending
meeting invitations and taking notes of meetings.
Undertake all
mandatory training and induction programs
Contribute to
and embrace the spectrum of clinical governance
Contribute to
public health campaigns (e.g. flu clinics) through advice or direct care
Liaise with professionals across Primary Care
& Social Care and co-ordinate the PCN MDT meetings.
Collate all a
patients identified care and support needs and review the options to meet
these needs and bring them into a single personalised care and support plan
(PCSP) in line with best practice
Promote Care
Co-ordination, its role in self-management, addressing health inequalities and
the wider determinants of health.
Raise awareness
within the PCN of shared decision making and decision support tools and
supporting people in shared decision-making conversations.
Engage with and
support the new and evolving agendas and service requirements across the PCN,
including our work with Care Homes residents and the need to proactively manage
their care in an individualised way.
Undertaking clinical
observations to support the plans, as appropriate.
Build relationships with staff in the GP
practices, attending relevant MDT meetings, giving information and feedback on
health coaching.
Provide education and
specialist expertise to fellow PCN staff, ensuring they are made aware of care
co-ordination, health and well-being coaching and social prescribing services
and support colleagues to improve their skills and understanding of
personalised care, behavioural approaches, and ensuring consistency in the
follow up of peoples goals where an MDT is involved.
This job description and the above areas of responsibility are an indication of the role and could be subject to change.
Job description
Job responsibilities
Care Co-Ordinators will:
Work closely
with practice and PCN healthcare roles, the PCC is to identify and work with a
cohort of people to support their personalised care requirements, using any
available decision support tools such as Patient Activation Measure (PAM),
templates and software
Meet patients, patient
carers and family members to discuss their personalised care requirements, the
services available to them and the help they want
Visit patients, checking
on the care that they have received and documenting it accordingly
Work with the care team
to evaluate interventions and identify where and when further ones will be
required
Help people
to manage their needs by answering their queries and supporting them in making
appointments
Support
people to access appropriate benefits where eligible as well as taking up
employment and training
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
Provide
patients with high quality, easy to understand information to assist them in
making choices about their care
Support
patients in understanding their level of knowledge, skills and confidence
(known as activation level) when participating in their health and well-being
using, where appropriate, the PAM
Liaise with
other PCCs in other practices across the region and share best practice
Assist
patients to access self-management education courses, peer support or
interventions that support them in their health and well-being
Where
appropriate, to assist patients to access personal health budgets
Provide coordination
and navigation of patients, and where appropriate their carers, across health
and social care services, where appropriate working hand in hand with social
prescribing link workers (SPLW)
Support in
the delivery of enhanced services and other service requirements on behalf of
the PCN
Lead in the
management of patient complaints and participate in the identification of any
necessary learning brought about through clinical incidents and near-miss
events
Actively participate in the delivery of multi-disciplinary
team (MDT) meetings within PCNs; responsible for preparatory admin, sending
meeting invitations and taking notes of meetings.
Undertake all
mandatory training and induction programs
Contribute to
and embrace the spectrum of clinical governance
Contribute to
public health campaigns (e.g. flu clinics) through advice or direct care
Liaise with professionals across Primary Care
& Social Care and co-ordinate the PCN MDT meetings.
Collate all a
patients identified care and support needs and review the options to meet
these needs and bring them into a single personalised care and support plan
(PCSP) in line with best practice
Promote Care
Co-ordination, its role in self-management, addressing health inequalities and
the wider determinants of health.
Raise awareness
within the PCN of shared decision making and decision support tools and
supporting people in shared decision-making conversations.
Engage with and
support the new and evolving agendas and service requirements across the PCN,
including our work with Care Homes residents and the need to proactively manage
their care in an individualised way.
Undertaking clinical
observations to support the plans, as appropriate.
Build relationships with staff in the GP
practices, attending relevant MDT meetings, giving information and feedback on
health coaching.
Provide education and
specialist expertise to fellow PCN staff, ensuring they are made aware of care
co-ordination, health and well-being coaching and social prescribing services
and support colleagues to improve their skills and understanding of
personalised care, behavioural approaches, and ensuring consistency in the
follow up of peoples goals where an MDT is involved.
This job description and the above areas of responsibility are an indication of the role and could be subject to change.
Person Specification
Qualifications
Essential
- Minimum English GCSE grade C or equivalent
- Minimum Maths GCSE grade C or equivalent
Desirable
- Customer Care Qualification
Experience
Essential
- Experience of working in a health care setting
Skills and Knowledge
Essential
- Computer literate with extensive experience of Microsoft Word, Outlook, Excel, PowerPoint and Access
- Excellent written, interpersonal and communication skills
- Ability to prioritise and have a flexible approach to workflows
- Strong focus on timely delivery of objectives and strong self-motivation
- Ability to communicate at all levels
- Active and empathetic listening
- Effective questioning
- Ability to build trust and rapport
- Professional behaviour at all times
- Effective time management
- Ability to work as a team member and autonomously
- Strong analytical thinking and ability to handle multiple tasks concurrently
- Ability to travel to locations across West Lancashire
- Experience of working in a Primary Care setting, healthcare environment and/or public sector is desirable
- Experience in working within a digital environment
- Planning and organisational skills
- Knowledge of the core concepts and principles of personalised care, shared decision making, patient activation, health behaviour change, self-efficacy, motivation and assets-based approaches
- Shared agenda setting/ collaborative goal setting/ shared follow-up planning
Desirable
- Knowledge of personalised care
Behaviours and Values
Essential
- Strives for safe, quality, effective and efficient service provision
- Promotes open and honest dialogue, valuing individual differences, respect aspirations and commitments, and seeks to understand priorities, needs, abilities and limits
- Aware of the impact of own behaviour on others
- Leads by example and actively role models the NHS and L&SC TH Values in all work, fostering an inclusive culture with compassion and humanity
- Interprets equality, diversity and rights in accordance with legislation, policies, procedures and good practice
- Constructively challenges and accepts feedback from others
- Maintains confidentiality at all times
Person Specification
Qualifications
Essential
- Minimum English GCSE grade C or equivalent
- Minimum Maths GCSE grade C or equivalent
Desirable
- Customer Care Qualification
Experience
Essential
- Experience of working in a health care setting
Skills and Knowledge
Essential
- Computer literate with extensive experience of Microsoft Word, Outlook, Excel, PowerPoint and Access
- Excellent written, interpersonal and communication skills
- Ability to prioritise and have a flexible approach to workflows
- Strong focus on timely delivery of objectives and strong self-motivation
- Ability to communicate at all levels
- Active and empathetic listening
- Effective questioning
- Ability to build trust and rapport
- Professional behaviour at all times
- Effective time management
- Ability to work as a team member and autonomously
- Strong analytical thinking and ability to handle multiple tasks concurrently
- Ability to travel to locations across West Lancashire
- Experience of working in a Primary Care setting, healthcare environment and/or public sector is desirable
- Experience in working within a digital environment
- Planning and organisational skills
- Knowledge of the core concepts and principles of personalised care, shared decision making, patient activation, health behaviour change, self-efficacy, motivation and assets-based approaches
- Shared agenda setting/ collaborative goal setting/ shared follow-up planning
Desirable
- Knowledge of personalised care
Behaviours and Values
Essential
- Strives for safe, quality, effective and efficient service provision
- Promotes open and honest dialogue, valuing individual differences, respect aspirations and commitments, and seeks to understand priorities, needs, abilities and limits
- Aware of the impact of own behaviour on others
- Leads by example and actively role models the NHS and L&SC TH Values in all work, fostering an inclusive culture with compassion and humanity
- Interprets equality, diversity and rights in accordance with legislation, policies, procedures and good practice
- Constructively challenges and accepts feedback from others
- Maintains confidentiality at all times
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.
