Job summary
An exciting new role for a Care Coordinator has arisen in Sedgefield North PCN - this is a part time position working 22 hours per week. Working arrangements can be condensed into 3 days, or more, if that is your preference. Friday working is required however other working days can be discussed with the successful candidate.
Interviews will be held in person, at St. Andrews Medical Practice on Wednesday, 12th February 2025.
In
your role you will work as part of the Sedgefield North PCN Integrated Care
Co-ordination Team and will be aligned to specific practice(s) within the PCN. You will be responsible for co-ordinating,
integrating and delivering support to practices patients.
You will ensure patients have good quality information to help them
make informed choices about their care by liaising with a broad range of
medical, social and third sector services.
You will ensure effective,
co-ordinated care is available to these patients, proactively identifying their
personalised care needs, using decision support aids as required. You will bring together the patients
identified care/ support needs and explore with them options to meet their
needs, recording them in a single personalised care and support plan (PCSP).
Please see JD for full details.
Main duties of the job
You will work with patients, their families, and carers, to improve their health and wellbeing by navigating them to the appropriate services. Ensuring they have good quality information to support their decision making, by taking a holistic approach. Bringing together all of their identified care and support requirements into a single personalised plan, based on what matters most to the patient. This could include access to self-management education courses, peer support or interventions that assist them in their health and wellbeing as well as supporting patients to take up training and employment.
You will guide them to access these services and any appropriate funding that is available to support them, includingaccess personal health budgets where appropriate.
By using Population Health Intelligence, the service may be targeted at specific patient groups, identified by the GP practices in the PCN. These patients will include but are not limited to: adults with complex long term health needs, depression, organic mental illness, and those who are at risk of social isolation.
You will be responsible to act on the follow up requirements contained in Secondary Care discharge letters, ensuring patients are aware of any additional monitoring or tests that are required and the timescales.
About us
Sedgefield North Primary Care Network is an innovative,
dynamic PCN combining 5 local GP Practices based in Spennymoor, Ferryhill &
Chilton, Sedgefield and West Cornforth with a population of over 58,000
patients. We are continually
seekingnew ways to support and improve local healthcare services to our
patient population.
An exciting opportunity has arisen for a Care Co-ordinator to
work as part of our newly established team, led by a Care Co-ordinator Team
Lead. You will join the growing multi-disciplinary team for the PCN which
includes Social Prescribing Link Workers, Clinical Pharmacists, Advanced Nurse
Practitioners and Primary Mental Health Nurses.
We are committed to the ongoing development of our team, which
includes mandatory and developmental training for all our staff. Team members
are encouraged to highlight any training they feel would benefit them in the
achievement of their role.
Job description
Job responsibilities
Main Duties and Areas of Responsibility:
Service Delivery
-
You will build and develop a robust knowledge and understanding of
health, social and third sector provision in the Primary Care Network area.
-
Develop good working relationships with
fellow Care Co-ordinators and Social Prescribing Link Workers and contribute to
the development of the Integrated Care Co-ordination Service for the PCN.
-
Develop strong working relationships with
clinical and non-clinical staff in your aligned GP practice and also with other
practices within the PCN
-
Develop a partnership working approach with workers from health, social
and third sector providers in the PCN area
-
Prepare proactive care plans for vulnerable patients.
-
Build relationships with patients, their families and carers. Carrying out regular visits, telephone
consultations and reviews within the community setting and at dedicated venues.
-
Be the patients advocate to the health and social care system.
-
Signpost patients to appropriate services and sources of funding and
where appropriate assist in accessing such funding.
Communication
-
Attend aligned practice level MDT meetings to discuss patients and coordinate
with other care providers as required.
-
Attend team meetings of the PCN Integrated Care Co-ordination Service
and report to the PCN Care Co-ordination Team Leader.
-
Utilise and demonstrate sensitive
communication styles, to ensure patients are fully informed.
-
Communicate with and support patients who are receiving bad news.
-
Communicate effectively with patients and carers, recognising the need
for alternative methods of communication to overcome different levels of
understanding, cultural background and preferred ways of communicating.
-
Anticipate barriers to communication and take action to overcome this.
-
Maintain effective communication within the practice environment and
with external stakeholders.
Delivering a quality
service
-
Produce accurate, contemporaneous and complete records of patient
contact, consistent with legislation, policies and procedures.
-
Prioritise, organise and manage own workload in a manner that maintains
and promotes quality.
-
Assess effectiveness of care delivery through self and peer review, benchmarking,
and formal evaluation.
-
Participate in the maintenance of quality governance systems and
processes across the organisation and its activities.
-
Utilise the audit cycle as a means of evaluating the quality of the work
of self and the team, implementing improvements where required.
-
In partnership with other clinical teams, collaborate on improving the
quality of health care responding to local and national policies and
initiatives as appropriate.
-
Evaluate patients responses to health care provision and the
effectiveness of care.
-
Support and participate in shared learning across the wider organisation.
-
Assess the impact of policy implementation on care delivery
-
Understand and apply legal issues that support the identification of
vulnerable and abused adults, and be aware of statutory vulnerable patients
health procedures and local guidance.
The post holder will comply with the
organisations policies and procedures:
Collaborative
Working Relationships
-
Understand your own role and scope, work within this scope of practice
and identify how this may develop over time.
-
Work as an effective and responsible team member, supporting others and
exploring the mechanisms to develop new ways of working.
-
Delegate clearly and appropriately, adopting the principles of safe
practice and assessment of competence.
-
Create clear referral mechanisms to meet patient need.
-
Actively work towards developing and maintaining effective working relationships
across the PCN.
-
Prioritise own workload and ensure
effective time-management strategies are embedded.
-
Work effectively with others to clearly define values, direction and
policies impacting upon care delivery.
-
Discuss, highlight and work with the team to create opportunities to
improve patient care.
-
Liaise with other stakeholders as needed for
the collective benefit of patients.
- Recognise personal limitations and refer to
more appropriate colleagues when necessary.
-
Actively work towards developing and
maintaining effecting working relationships across the PCN.
-
Foster and maintain strong links with all
services across locality.
-
Explore the potential for collaborative
working and take opportunities to initiate and sustain such relationships.
Managing information
-
Use technology and appropriate software as an aid to management in
planning, implementation and monitoring of care, presenting and communicating
information.
-
Ensure that patient data is kept confidential at all times and is shared
on a need to know basis only.
-
Understand responsibility of self and others regarding the Freedom of
Information Act
-
Collate, analyse and present data and information to the team.
Education,
Training and Development
-
Understand and demonstrate the characteristics
of a role model to members in the team and/or service.
-
Disseminate learning and information gained to other team members in
order to share good practice and inform others about current and future
developments (e.g. courses and conferences).
-
Assess own learning needs and undertake learning as appropriate.
-
Demonstrate self-development through
continuous professional development activity; working alongside colleagues to
identify areas to develop.
-
Enrol into review and appraisal systems within
the network.
Equality and Diversity
- You must co-operate with all policies and
procedures designed to ensure equality of employment. Co-workers, patients and visitors must be
treated equally irrespective of gender, ethnic origin, age, disability, sexual
orientation, religion etc.
- You must demonstrate respect for patient
confidentiality at all times
- You should respect patient confidentiality at
all times and not divulge patient information unless sanctioned by the
requirements of the role.
Special
Working Conditions
You will be required to travel independently
between practice sites (where applicable), patients homes, community settings and
to attend meetings with other agencies. Ability to drive and access to a
vehicle will be required.
Job
Description Agreement
This job description is intended to provide an
outline of the key tasks and responsibilities only. There may be other duties
required of the post-holder commensurate with the position. This description
will be open to regular review and may be amended to take into account
development within the network. All members of staff should be prepared to take
on additional duties or relinquish existing duties in order to maintain the
efficient running of the network.
This job description is intended as a basic
guide to the scope and responsibilities of the post and is not exhaustive. It
will be subject to regular review and amendment as necessary in consultation
with the post-holder.
Health
and Safety/Risk Management
You must comply at all times with the
Practices Health and Safety policies, in particular by following agreed safe
working procedures and reporting incidents using the organisations Incident
Reporting System.
You must comply with the Data Protection Act
(2018) and the Access to Health Records Act (1990).
Job description
Job responsibilities
Main Duties and Areas of Responsibility:
Service Delivery
-
You will build and develop a robust knowledge and understanding of
health, social and third sector provision in the Primary Care Network area.
-
Develop good working relationships with
fellow Care Co-ordinators and Social Prescribing Link Workers and contribute to
the development of the Integrated Care Co-ordination Service for the PCN.
-
Develop strong working relationships with
clinical and non-clinical staff in your aligned GP practice and also with other
practices within the PCN
-
Develop a partnership working approach with workers from health, social
and third sector providers in the PCN area
-
Prepare proactive care plans for vulnerable patients.
-
Build relationships with patients, their families and carers. Carrying out regular visits, telephone
consultations and reviews within the community setting and at dedicated venues.
-
Be the patients advocate to the health and social care system.
-
Signpost patients to appropriate services and sources of funding and
where appropriate assist in accessing such funding.
Communication
-
Attend aligned practice level MDT meetings to discuss patients and coordinate
with other care providers as required.
-
Attend team meetings of the PCN Integrated Care Co-ordination Service
and report to the PCN Care Co-ordination Team Leader.
-
Utilise and demonstrate sensitive
communication styles, to ensure patients are fully informed.
-
Communicate with and support patients who are receiving bad news.
-
Communicate effectively with patients and carers, recognising the need
for alternative methods of communication to overcome different levels of
understanding, cultural background and preferred ways of communicating.
-
Anticipate barriers to communication and take action to overcome this.
-
Maintain effective communication within the practice environment and
with external stakeholders.
Delivering a quality
service
-
Produce accurate, contemporaneous and complete records of patient
contact, consistent with legislation, policies and procedures.
-
Prioritise, organise and manage own workload in a manner that maintains
and promotes quality.
-
Assess effectiveness of care delivery through self and peer review, benchmarking,
and formal evaluation.
-
Participate in the maintenance of quality governance systems and
processes across the organisation and its activities.
-
Utilise the audit cycle as a means of evaluating the quality of the work
of self and the team, implementing improvements where required.
-
In partnership with other clinical teams, collaborate on improving the
quality of health care responding to local and national policies and
initiatives as appropriate.
-
Evaluate patients responses to health care provision and the
effectiveness of care.
-
Support and participate in shared learning across the wider organisation.
-
Assess the impact of policy implementation on care delivery
-
Understand and apply legal issues that support the identification of
vulnerable and abused adults, and be aware of statutory vulnerable patients
health procedures and local guidance.
The post holder will comply with the
organisations policies and procedures:
Collaborative
Working Relationships
-
Understand your own role and scope, work within this scope of practice
and identify how this may develop over time.
-
Work as an effective and responsible team member, supporting others and
exploring the mechanisms to develop new ways of working.
-
Delegate clearly and appropriately, adopting the principles of safe
practice and assessment of competence.
-
Create clear referral mechanisms to meet patient need.
-
Actively work towards developing and maintaining effective working relationships
across the PCN.
-
Prioritise own workload and ensure
effective time-management strategies are embedded.
-
Work effectively with others to clearly define values, direction and
policies impacting upon care delivery.
-
Discuss, highlight and work with the team to create opportunities to
improve patient care.
-
Liaise with other stakeholders as needed for
the collective benefit of patients.
- Recognise personal limitations and refer to
more appropriate colleagues when necessary.
-
Actively work towards developing and
maintaining effecting working relationships across the PCN.
-
Foster and maintain strong links with all
services across locality.
-
Explore the potential for collaborative
working and take opportunities to initiate and sustain such relationships.
Managing information
-
Use technology and appropriate software as an aid to management in
planning, implementation and monitoring of care, presenting and communicating
information.
-
Ensure that patient data is kept confidential at all times and is shared
on a need to know basis only.
-
Understand responsibility of self and others regarding the Freedom of
Information Act
-
Collate, analyse and present data and information to the team.
Education,
Training and Development
-
Understand and demonstrate the characteristics
of a role model to members in the team and/or service.
-
Disseminate learning and information gained to other team members in
order to share good practice and inform others about current and future
developments (e.g. courses and conferences).
-
Assess own learning needs and undertake learning as appropriate.
-
Demonstrate self-development through
continuous professional development activity; working alongside colleagues to
identify areas to develop.
-
Enrol into review and appraisal systems within
the network.
Equality and Diversity
- You must co-operate with all policies and
procedures designed to ensure equality of employment. Co-workers, patients and visitors must be
treated equally irrespective of gender, ethnic origin, age, disability, sexual
orientation, religion etc.
- You must demonstrate respect for patient
confidentiality at all times
- You should respect patient confidentiality at
all times and not divulge patient information unless sanctioned by the
requirements of the role.
Special
Working Conditions
You will be required to travel independently
between practice sites (where applicable), patients homes, community settings and
to attend meetings with other agencies. Ability to drive and access to a
vehicle will be required.
Job
Description Agreement
This job description is intended to provide an
outline of the key tasks and responsibilities only. There may be other duties
required of the post-holder commensurate with the position. This description
will be open to regular review and may be amended to take into account
development within the network. All members of staff should be prepared to take
on additional duties or relinquish existing duties in order to maintain the
efficient running of the network.
This job description is intended as a basic
guide to the scope and responsibilities of the post and is not exhaustive. It
will be subject to regular review and amendment as necessary in consultation
with the post-holder.
Health
and Safety/Risk Management
You must comply at all times with the
Practices Health and Safety policies, in particular by following agreed safe
working procedures and reporting incidents using the organisations Incident
Reporting System.
You must comply with the Data Protection Act
(2018) and the Access to Health Records Act (1990).
Person Specification
Qualifications
Essential
- GCSE Grade C or above in Maths and English, or equivalent qualification.
Desirable
- Qualification in a health or social care allied profession.
Knowledge and Skills
Essential
- Demonstrate an appreciation of the health needs of the patient population within the Primary care network.
Desirable
- Knowledge of the geographical area within the Primary care Network.
- Understanding of safeguarding principles.
- Knowledge of local health and social care provision.
- Knowledge of funding systems in social care.
- Experience using SystmOne.
Person Specification
Qualifications
Essential
- GCSE Grade C or above in Maths and English, or equivalent qualification.
Desirable
- Qualification in a health or social care allied profession.
Knowledge and Skills
Essential
- Demonstrate an appreciation of the health needs of the patient population within the Primary care network.
Desirable
- Knowledge of the geographical area within the Primary care Network.
- Understanding of safeguarding principles.
- Knowledge of local health and social care provision.
- Knowledge of funding systems in social care.
- Experience using SystmOne.
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.
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