Care Coordinator and Community Engagement Officer

Job description

Job responsibilities

The post holder, working closely with the PCN team, Care Home, GP’s and existing community services will: 

• Coordinate Multi-Disciplinary Team meetings for people living in care homes

• Utilise Population Health Intelligence to proactively identify care home residents and work with the PCN team to enable the PCN team to deliver personalised care

• Utilise Population Health Intelligence tools where needed to support other patients in the PCN. 

• Strengthening relationships with community partners, identifying and addressing improvements to working together to authentically support local population including implementation of continued engagement strategies.

 Additional Responsibilities 

• Be responsible for daily updating of patients on e-HealthScope Workflow to identify care residents to support the PCN team with identifying community pathways that might prevent hospital admission and for identifying potential gaps in care.

• Be responsible for arranging, attending and minuting Care home Multi-Disciplinary Team Meetings.

• Proactively prepare any actions prior to the MDT ensuring all relevant clinicians are present. 

• To record patient interventions on relevant electronic database systems (e.g. SystmOne) and contribute to report generation, analysis and production. 

• Follow up on all forward actions resulting from MDT discussions.

• Be responsible for logging and making referrals. 

• To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team and providing information to any member of the PCN Team, in order to ease processes and communication in agreement with data protection protocol. 

• To be responsible for recording, reporting and producing evaluation reports which will include evaluation detailing effectiveness outcomes of new roles.

• To be customer (patient, carer, GP) focused when representing the service. 

• To work collaboratively with other teams and services to maintain an effective and efficient service.

• To offer appropriate support and guidance to patients and their families/carers. 

• Support a range of community engagement and consultation initiatives as directed by the Leadership team.

• Support the development of a Community Engagement plan, which creates and nurtures a positive relationship between Mansfield North PCN and its community partners.

• Provide an outreach and support service to local organisations and community groups to further extend the PCN’s reach into the local key priority areas.

• Support a programme of co-production with community partners on potential developments working collaboratively with local population residing in key priority areas.

• To work closely with PCN staff ie Social Prescribing Link Workers and Health & Wellbeing Coaches to provide a comprehensive and effective signposting service to Mansfield North residents

• Based on effective two-way relationships with the community, feed relevant information through to colleagues to inform the PCN’s delivery programmes.

• Attend community meetings and events on behalf of Mansfield North PCN to listen and engage in conversations about local issues and update them on the PCN’s activities - this will at times require evening and weekend working. 

• Build closer links with the community partners through a series of networking events to ensure they have access to additional support from the various departments within the Trust.

• To plan / organise work using own initiative, whilst being able to work as a valuable member of a team 

• To have excellent IT skills, to include Microsoft Office, Outlook and Excel 

• To undertake general office duties to support the role 

• To work effectively as part of a team to provide cover for Care Coordination Teams when required and to be flexible regarding working hours to meet the needs of the service

• To ensure all electronic records are updated and complete within the agreed time scales

• To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleague

• Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested 

• Support the PCN team by inputting into the overall strategy development and programming of work streams by applying knowledge and understanding of programme and project management 

• Work with key personnel in the PCN to develop & support collective general practice projects including areas of federated working 

• Work towards completing the appropriate training to deliver and support the Comprehensive Model for Personalised Care

• Work closely and in partnership with the Social Prescribing Link Worker(s) 

• Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested

• To participate in the review and appraisal process 

• To carry out any other reasonable duties as requested by a manager to ensure quality of service 

• To participate in any relevant training/courses/conferences 

• Complete mandatory training

 The post holder will be able to:

• Use clinical systems for record keeping, audit and evaluation

• Develop and implement data collection systems that will provide accurate and timely data.

• Maintain confidentiality 

• Build and maintain strong relationships; Foster trust and co-operation among colleagues, community leaders and partners, commissioners.

• Be proactive and work independently. 

• Demonstrate an understanding of the needs of the local population Professional Development / Personal Performance.

• Identify learning needs, plan, implement and evaluate programmes of education to meet identified need. 

• Establish own support mechanisms to enable structured reflection, including supervision, development of supportive networks mentoring and coaching. 

• Participate in and undertake supervision of colleagues on an individual or group 

• Participate in the Divisional appraisal System and demonstrate the achievement of agreed personal objectives.

 Physical and Mental Skills

• The post holder should be physically fit for the role with the necessary keyboard and IT skills. 

• Required to communicate across the health community and with patients / carers where the nature of the information given may be sensitive and could be disputed.

For more information please see the supporting documents 

Person Specification

Experience

Essential

• Please provide detailed information of how you feel that your experience is suitable for this role; please provide examples to support your application referring to the job description and person specification for guidance.

Personal Qualities

Essential

• Please provide details for why you would be a great fit for this role and why you have decided to apply.

Knowledge and Skills

Essential

• Please provide detailed information of how you feel that your knowledge and skills are suitable for this role; please provide examples to support your application referring to the job description and person specification for guidance.

Qualifications

Essential

• Please provide details of your CPD, using examples where necessary.

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.

Employer details

Employer name

Primary Integrated Community Services

Address

Mansfield North Primary Care Network

Nottingham

NG19 8BL

Employer's website

http://picsnhs.org.uk/ (Opens in a new tab)