Job summary
Exciting Opportunity:Long Term ConditionsCare Coordinator Make a Real Difference!
Are you passionate about improving lives and helping others navigate their health journey? Join our dynamic PCN team as a Long Term ConditionsCare Coordinatorfor 22.5 hours per week over 3-4 days and play a pivotal role in supporting individuals with long-term conditions. You'll work closely with both the Practice and ICC teams, managing a personalized caseload and acting as a central point of contact for patients and their carers.
In this rewarding, non-clinical role, you'll help people access essential services, from social prescribing to community-based support, empowering them to better manage their conditions and improve their overall quality of life. Its a chance to make a meaningful impact every day while working in a collaborative, supportive environment.
If you're ready to take on a role that truly makes a difference, we want to hear from you!
Closing Date: 25 February 2025
WHEN APPLYING
FOR THIS ROLE, PLEASE INCLUDE YOUR MOBILE NUMBER ON YOUR APPLICATION SO WE CAN
CONTACT YOU IF NEEDED. PLEASE ALSO CHECK YOUR SPAM OR JUNK FOLDER REGULARLY AS
EMAILS FROM US MAY OCCASIONALLY BE FILTERED THERE.
We encourage
you to apply as early as possible as this job may close earlier than the
advertised closing date once enough applications have been received
Please note
that we are unable to offer an Employer Sponsored Visa for this role.
Main duties of the job
The Care Co-ordinator will play an important role within the PCN to proactively identify and work with people, particularly those with long term conditions, to provide co-ordination and navigation of care and support across health and care services.
Care co-ordinators review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers and other professionals and community-based services as appropriate. The aim is to help people manage their conditions better and improve their quality of life.
The role of a care co-ordinator is not a clinical role.
All staff are expected to work to Cumbria Healths Values:
- Clinically focused - Everything every one of us does is for the patient
- Responsive - We listen and we respond quickly in a patient focussed way
- One Team - We work together to provide a high quality service which is organised and consistent, and in partnership with both the local Acute and Community Trusts
- Growth & Sustainability - With our strong roots we will continue to thrive and grow.
- Communities - Connecting with communities to meet local needs.
- High Standards - We provide skilled professionals working to the highest standards who are passionate about improving patient care
About us
Cumbria Health on Call - CH places the patient, their family and their community at the heart of everything we do. We are an award-winning organisation, the first out-of-hours organisation in the country to be rated as outstanding by the Care Quality Commission (CQC).
We provide primary health care services, both in and out of hours, across Cumbria. We are values-driven and place great emphasis on inclusivity and the wellbeing and development of our staff, while striving to provide a consistently high-quality service. Our service is designed to improve health and wellbeing.
Working for CH can offer flexible opportunities in terms of location, hours and working patterns so you can enjoy a great work life balance. In order to provide the best patient care we understand the importance of ensuring staff satisfaction and are consistently trying to ensure we offer our staff a positive working environment whether that be though training or social events.
Listen to your heart. Have the work life balance you'd love.
Job description
Job responsibilities
This list of duties and responsibilities, which follows, represents the broad range of tasks which may be required to be undertaken either routinely or periodically. This list is not exhaustive, and the role may include additional duties which are not listed here.
- Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes
- Work collaboratively with the practice team to proactively identify patients with long-term conditions to add to their caseload
- To refer back to, or liaise with, health and care staff as appropriate to help meet the needs of the patient.
- Support PCNs in developing communication channels between GPs, people and their families
- Work with people and their families and carers and healthcare team members to encourage effective help-seeking behaviours
- Maintain records of referrals and interventions to enable monitoring and evaluation of the service
Key tasks
Enable access to personalised care and support
- Take referrals for individuals or proactively identify people who could benefit from support through care co-ordination
- Have a positive, empathetic and responsive conversation with the person and their family and carers about their needs
- Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance
- Pro-actively develop an in-depth knowledge of, and links with, the local health and care infrastructure and know how and when to enable people to access support and services that are right for them
- Support people to develop and implement personalised care and support plans
- Write care and support plans which are simple, co-produced and personalised
- Ensure patients are clear what to expect from the groups, activities and services they are supported to connect with
- Be supportive but promote what the person can do for themselves to improve their health and wellbeing
- Review and update personalised care and support plans at regular intervals
- Ensure plans are clearly recorded in the patients electronic record to communicate with the practice team and other professionals involved in the patients care.
- To be involved in multidisciplinary clinical meetings within the practice, the ICC and across the PCN where appropriate
Co-ordinate and integrate care
- Make, manage and support attendance at appointments/activities for patients in health and statutory services and in the community.
- Refer onwards to health and council social prescribing link workers and health and wellbeing coaches where required
- Actively participate in multi-disciplinary meetings about the patient to keep everyone informed
- Identify when action or additional support is needed, alerting a named clinical contact in addition to other relevant care professionals, and highlighting any safety concerns
- Assist people to access self-management education courses, peer support or interventions and activities that support them in their health and wellbeing and increase their activation level
- Record what interventions are used to support people and how people are developing on their health and care journey
- Keep accurate and up-to-date records of contacts using appropriate clinical templates and coding within EMIS, adhering to information governance and data protection legislation.
- Support the achievement of practice local and national quality standards, e.g. QOF, IIF and GPQC
- Support early diagnosis and prevention of cancer, encouraging take-up of screening and understanding of symptoms
- Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives
- Record and collate information according to agreed protocols and contribute to evaluation reports require for the monitoring and evaluation of the service.
- To undertake a proactive role in audit and quality improvement implementing recommendations where appropriate
- Work with practice to ensure full compliance with Care Quality Commission standards for safe and effective care.
- Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonable required from time-to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
Professional Development
- Work with a named clinical 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.
Job description
Job responsibilities
This list of duties and responsibilities, which follows, represents the broad range of tasks which may be required to be undertaken either routinely or periodically. This list is not exhaustive, and the role may include additional duties which are not listed here.
- Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes
- Work collaboratively with the practice team to proactively identify patients with long-term conditions to add to their caseload
- To refer back to, or liaise with, health and care staff as appropriate to help meet the needs of the patient.
- Support PCNs in developing communication channels between GPs, people and their families
- Work with people and their families and carers and healthcare team members to encourage effective help-seeking behaviours
- Maintain records of referrals and interventions to enable monitoring and evaluation of the service
Key tasks
Enable access to personalised care and support
- Take referrals for individuals or proactively identify people who could benefit from support through care co-ordination
- Have a positive, empathetic and responsive conversation with the person and their family and carers about their needs
- Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance
- Pro-actively develop an in-depth knowledge of, and links with, the local health and care infrastructure and know how and when to enable people to access support and services that are right for them
- Support people to develop and implement personalised care and support plans
- Write care and support plans which are simple, co-produced and personalised
- Ensure patients are clear what to expect from the groups, activities and services they are supported to connect with
- Be supportive but promote what the person can do for themselves to improve their health and wellbeing
- Review and update personalised care and support plans at regular intervals
- Ensure plans are clearly recorded in the patients electronic record to communicate with the practice team and other professionals involved in the patients care.
- To be involved in multidisciplinary clinical meetings within the practice, the ICC and across the PCN where appropriate
Co-ordinate and integrate care
- Make, manage and support attendance at appointments/activities for patients in health and statutory services and in the community.
- Refer onwards to health and council social prescribing link workers and health and wellbeing coaches where required
- Actively participate in multi-disciplinary meetings about the patient to keep everyone informed
- Identify when action or additional support is needed, alerting a named clinical contact in addition to other relevant care professionals, and highlighting any safety concerns
- Assist people to access self-management education courses, peer support or interventions and activities that support them in their health and wellbeing and increase their activation level
- Record what interventions are used to support people and how people are developing on their health and care journey
- Keep accurate and up-to-date records of contacts using appropriate clinical templates and coding within EMIS, adhering to information governance and data protection legislation.
- Support the achievement of practice local and national quality standards, e.g. QOF, IIF and GPQC
- Support early diagnosis and prevention of cancer, encouraging take-up of screening and understanding of symptoms
- Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives
- Record and collate information according to agreed protocols and contribute to evaluation reports require for the monitoring and evaluation of the service.
- To undertake a proactive role in audit and quality improvement implementing recommendations where appropriate
- Work with practice to ensure full compliance with Care Quality Commission standards for safe and effective care.
- Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonable required from time-to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
Professional Development
- Work with a named clinical 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.
Person Specification
Qualifications
Essential
- GCSE Grade A-C in Maths & English, or equivalent
Desirable
- NVQ level 3 in adult care advanced level or equivalent qualifications nor working towards
- Is enrolled in, undertaking, or qualified in appropriate training as set out in the core curriculum by the Personalised Care Institute
Personal Attributes & Abilities
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to maintain effective working relationships and promote collaborative practice with all colleagues
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Ability to provide motivational coaching to support peoples behaviour change
- Ability to co-ordinate and prioritise workloads able to multi-task as well as be self-disciplined and highly motivated
Desirable
- High degree of personal credibility, emotional intelligence, patience and flexibility
- Ability to cope with unpredictable situations
- Confident in facilitating and challenging others
- Demonstrates a flexible approach in order to ensure patient care is delivered
Experience
Essential
- Demonstrable patient assessment skills
- Experience of working in multi-disciplinary teams
Desirable
- Experience working in primary care or adult social care
- Experience of working in a care co-ordinator role
Communication
Essential
- Excellent interpersonal and communication skills
- Build effective relationships with a range of stakeholders which are based on openness, honesty trust and confidence
- Ability to communicate effectively both verbally and in writing with people, families, carers, community groups, health and other statutory agencies and stakeholders.
Desirable
- Clear communicator with excellent writing, report writing and presentation skills.
Knowledge
Essential
- Knowledge of the personalised care approach
- Understanding of social, economic and environment factors on health of patients, families and carers
Desirable
- Familiarity with GP computer systems such as EMIS.
- Knowledge of how the NHS works, including primary care and PCNs
- Basic understanding of long-term conditions
- Understanding safeguarding principles
Person Specification
Qualifications
Essential
- GCSE Grade A-C in Maths & English, or equivalent
Desirable
- NVQ level 3 in adult care advanced level or equivalent qualifications nor working towards
- Is enrolled in, undertaking, or qualified in appropriate training as set out in the core curriculum by the Personalised Care Institute
Personal Attributes & Abilities
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to maintain effective working relationships and promote collaborative practice with all colleagues
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Ability to provide motivational coaching to support peoples behaviour change
- Ability to co-ordinate and prioritise workloads able to multi-task as well as be self-disciplined and highly motivated
Desirable
- High degree of personal credibility, emotional intelligence, patience and flexibility
- Ability to cope with unpredictable situations
- Confident in facilitating and challenging others
- Demonstrates a flexible approach in order to ensure patient care is delivered
Experience
Essential
- Demonstrable patient assessment skills
- Experience of working in multi-disciplinary teams
Desirable
- Experience working in primary care or adult social care
- Experience of working in a care co-ordinator role
Communication
Essential
- Excellent interpersonal and communication skills
- Build effective relationships with a range of stakeholders which are based on openness, honesty trust and confidence
- Ability to communicate effectively both verbally and in writing with people, families, carers, community groups, health and other statutory agencies and stakeholders.
Desirable
- Clear communicator with excellent writing, report writing and presentation skills.
Knowledge
Essential
- Knowledge of the personalised care approach
- Understanding of social, economic and environment factors on health of patients, families and carers
Desirable
- Familiarity with GP computer systems such as EMIS.
- Knowledge of how the NHS works, including primary care and PCNs
- Basic understanding of long-term conditions
- Understanding safeguarding principles
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.
