Job summary
Care
Co-ordinator roles are new to Primary Care and we are looking to recruit a Hospital
Discharge Care Co-ordinators within the Tame Valley Primary Care Network (PCN).
This role will involve working with patients with a range of presentations and
also their families and carers.
The care co-ordinator will be integral in
overseeing the interdisciplinary care and will be responsible for co-ordinating
a package of care and support from a variety of specialists who may be working
with the patient.
Main duties of the job
The Care Co-ordinator will support all key activity across the PCN; supporting the
PCN manager and associated practices by co-ordinating activity and providing an
efficient, well organised administrative and operational support to the
clinicians and managers in the network to ensure effective timely delivery of
the PCN objectives.
The Care Co-ordinator will ensuring all relevant services, acute, community, primary
care, social care, housing and voluntary, are linked in order to co-ordinate
care and support for patients during and following discharge and to prevent
re-admissions.
About us
Viaduct Care is the GP Federation and is a partnership of all GP practices across Stockport.
The federation was formed to empower local GPs to provide the best possible care for patients whilst tackling some of the challenges faced by General Practice by helping doctors and other healthcare professionals work together, share resources and expertise.
Our vision is to be consistently recognised for enabling the delivery of high quality patient centred healthcare, which is innovative, equitable, efficient, effective and contributing to a healthy population in Stockport.
Whatever stage you’re at in your career, we’ll provide you with the high-quality support you need to continue developing your skills, achieve job satisfaction and help shape the future of healthcare to make a real difference to people’s lives.
Job description
Job responsibilities
Main Roles & Responsibilities:
· Responsible for developing timely and person-centred ‘step-down’ or ‘step-up’ plans for patients based on the principle of ‘no place like home’.
· Understand the discharge home pathways, communicating with a clear and consistent focus on ‘discharge to assess’ (D2A) and ‘home first’.
· Support safe discharges of people on pathways 1 to 3 through close working with secondary care, quality assurance of information and practical support.
· Communicate with Hospital discharge teams improving commitment from all partners to the D2A and home first.
· Contact patients following a hospital discharge and assess their short and long-term needs and link the patient to appropriate support to aid their recovery.
· Ensure the person and any carers, family or friends are involved in and informed about what is happening and when.
· Identify and remove blockages and, where necessary, change processes to improve patient discharge requirements.
· Ensure clear patient recovery plans are created.
· Closely monitor and document progress against the recovery and support plan.
· Ensure adjustments are made to the support provided as required and in a timely way and the support is ended when it is no longer needed.
· After a sufficient period of recover, where it appears a person may need support on a long-term basis, liaise with appropriate professionals to ensure timely assessment, for example a Care Act (2014) assessment or NHS continuing health care assessment (or both).
· Arrange necessary primary care follow-ups with GPs and Practice Nurses
It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role.
Job description
Job responsibilities
Main Roles & Responsibilities:
· Responsible for developing timely and person-centred ‘step-down’ or ‘step-up’ plans for patients based on the principle of ‘no place like home’.
· Understand the discharge home pathways, communicating with a clear and consistent focus on ‘discharge to assess’ (D2A) and ‘home first’.
· Support safe discharges of people on pathways 1 to 3 through close working with secondary care, quality assurance of information and practical support.
· Communicate with Hospital discharge teams improving commitment from all partners to the D2A and home first.
· Contact patients following a hospital discharge and assess their short and long-term needs and link the patient to appropriate support to aid their recovery.
· Ensure the person and any carers, family or friends are involved in and informed about what is happening and when.
· Identify and remove blockages and, where necessary, change processes to improve patient discharge requirements.
· Ensure clear patient recovery plans are created.
· Closely monitor and document progress against the recovery and support plan.
· Ensure adjustments are made to the support provided as required and in a timely way and the support is ended when it is no longer needed.
· After a sufficient period of recover, where it appears a person may need support on a long-term basis, liaise with appropriate professionals to ensure timely assessment, for example a Care Act (2014) assessment or NHS continuing health care assessment (or both).
· Arrange necessary primary care follow-ups with GPs and Practice Nurses
It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role.
Person Specification
Knowledge and Skills
Essential
- Ability to recognise and respond appropriately to risk and safeguarding concerns.
- Knowledge around importance of confidentiality and data protection.
- Good communication and interpersonal skills, including an ability to build rapport and establish good one to one relationships
- Ability to deal with challenging behaviour and difficult conversations.
- Be able to offer support in a person centred and non-judgmental way.
- Ability to effectively manage a variable workload.
- Ability to maintain accurate and concise records.
- Ability to provide information effectively.
- Good IT skills and proficient in the use of various Microsoft packages.
- Willingness to work in settings across Stockport.
- Commitment to working towards Viaduct Care CICs values and ethos as an organisation.
- Ability to work flexibly in an innovative and developing role.
Experience
Essential
- Previous experience working with the general public.
- Experience of working autonomously and part of a team.
Desirable
- Experience of hospital discharge.
- Experience of working in Primary Care.
- Experience of working with Older Adults/Dementia/Learning Disabilities/Safeguarding.
- Experience of working with individuals with long term conditions.
- Evidence of working within a multidisciplinary team.
- Experience of working without direct supervision.
Qualifications
Essential
- Achieved grade C or above, in English and Maths GCSE or equivalent.
- NVQ Level III (Health and Social Care) or equivalent or equivalent experience.
Desirable
- Formal training in working with long term conditions.
Person Specification
Knowledge and Skills
Essential
- Ability to recognise and respond appropriately to risk and safeguarding concerns.
- Knowledge around importance of confidentiality and data protection.
- Good communication and interpersonal skills, including an ability to build rapport and establish good one to one relationships
- Ability to deal with challenging behaviour and difficult conversations.
- Be able to offer support in a person centred and non-judgmental way.
- Ability to effectively manage a variable workload.
- Ability to maintain accurate and concise records.
- Ability to provide information effectively.
- Good IT skills and proficient in the use of various Microsoft packages.
- Willingness to work in settings across Stockport.
- Commitment to working towards Viaduct Care CICs values and ethos as an organisation.
- Ability to work flexibly in an innovative and developing role.
Experience
Essential
- Previous experience working with the general public.
- Experience of working autonomously and part of a team.
Desirable
- Experience of hospital discharge.
- Experience of working in Primary Care.
- Experience of working with Older Adults/Dementia/Learning Disabilities/Safeguarding.
- Experience of working with individuals with long term conditions.
- Evidence of working within a multidisciplinary team.
- Experience of working without direct supervision.
Qualifications
Essential
- Achieved grade C or above, in English and Maths GCSE or equivalent.
- NVQ Level III (Health and Social Care) or equivalent or equivalent experience.
Desirable
- Formal training in working with long term conditions.
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.
