Job summary
Care Coordinators support patients in preparing for or in following-up clinical conversations they have with primary care professionals. Care Coordinators also support existing community groups to be accessible and sustainable and help the Social Prescribing team to assist people to start new community groups, where appropriate, working collaboratively with all local partners.
The Care Coordinator will work as a key part of the Primary Care Network (PCN) multi-disciplinary team, helping PCNs to strengthen community and personal resilience and reduce health and wellbeing inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity, by increasing peoples active involvement with their local diverse communities.
Main duties of the job
This role has been funded for 12 months to support Red House practice. The care Co-ordinator will lead a pilot working with families who are disengaged in healthcare, and have low activation which may impact the whole the whole family
Individuals and their families are missing out on-
Chronic Disease reviews
LD checks
Vaccination/immunisation
Screening
About us
Sunderland GP Alliance began in 2015 and as a limited company we have grown to over 200 employees today. We are innovative in responding to the changing needs of a 21st century health care system. With a not-for-profit ethos people are at the heart of everything we do. Whether it is a patient being seen at one of our GP practices or out of hours service, or the people at the heart of the Alliance who make it a great friendly place to work. We want people to realise their potential inside and outside of work which is why we support your development and offer 33 days holiday plus bank holidays.
Date posted
16 September 2024
Pay scheme
Other
Salary
£27,003.42 a year Pro-rata for part-time
Contract
Fixed term
Duration
12 months
Working pattern
Part-time
Reference number
U0012-24-0055
Job locations
North East BIC
Wearfield
Sunderland
Tyne and Wear
SR5 2TA
Job description
Job responsibilities
Main Duties and Responsibilities
Proactively identify people to support their personalised care requirements, using the available decision support aids.
Telephone triage all incoming referrals to bring together all of a persons identified care and support needs, and explore their options to meet these via a single personalised care and support plan, or seamlessly refer cases, if necessary, to appropriate professionals.
Help people to manage their needs, answering their queries and supporting them to make appointments or to take up training and employment, and to access appropriate benefits where eligible.
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the Patient Activation Measure.
Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision making conversation.
Ensure that people have good quality information to help them make choices about their care,
Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame
To be the first point of contact for GP practices, MDT and Social Prescribing Link Workers, as well as a direct link for the wider system across the city.
Support the identification of patients for inclusion in MDTs within PCNs.
Support the collection of patient data for analysis of outcome measure for service interpretation and growth
Education
Promote social prescribing across the PCN, Health & Social Care professionals and the wider system, including its role in self-management, addressing health inequalities and the wider determinants of health.
Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health access and outcomes and enable a holistic approach to care.
Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals.
Referrals
Receive and action referrals for social prescriptions via agreed systems.
Manage and prioritise referrals appropriately.
Redirect referrals, using the agreed protocols, to more appropriate Link workers or agencies.
Be proactive in developing strong links with all local agencies to encourage referrals.
Support referral agencies to provide appropriate information about the person they are referring.
Provide appropriate monitoring and review of referrals received and feedback to referral agencies.
Adhere to data protection legislation and data sharing agreements.
Personalised Support
Work collaboratively & be proactive in encouraging equality and inclusion, through connecting with diverse local communities, particularly those communities that statutory agencies may find hard to reach.
Build trust and respect within the wider team, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on community assets.
Be an engaging source of information about health, wellbeing and prevention approaches.
Analyse data outcomes and identify what individuals expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
Follow up with patients to ensure they are happy, able to engage, included and receiving good support.
Support with patient queries where appointed Social Prescribing Link Worker is unavailable and provide cover during annual leave
Undertake patient and provider surveys to support service development
Community Asset Development
Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing.
Support community groups and VCSE organisations to receive referrals
Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of diverse community groups and assets, who promote diversity and inclusion.
Develop supportive relationships with local VCSE organisations, culturally appropriate community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced.
Work collectively with all local partners to ensure community groups are strong and sustainable
Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision.
Collaborative working
As part of the PCN multi-disciplinary team, build close working relationships with staff in GP practices within the local PCN, giving information and feedback on social prescribing.
Work with established VCSE organisations and existing Link Workers to provide a robust and consistent approach to our Sunderland people.
Explore ways of working and share good practice and learning across all social prescribing roles within the system.
Data Collection & Analysis
Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.
Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing.
Analyse types of referrals, cohorts and end points to support identification of gaps in provision and produce documentation for service interpretation.
Proactively identify cohorts of patients, utilising close links with LA, PHE and GP Practices, that may benefit from accessing Social Prescribing Service
Professional Development
Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities.
Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Service Development
Seek regular feedback about the quality of the service and impact of social prescribing on referral agencies.
Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
Contribute to the development of policies and plans relating to equality, diversity and health inequalities.
Leadership
Support the social prescribing team in the development, delivery and education of social prescribing and health coaching, ensuring involvement where value can be added.
Provide administrative and advisory support to the social prescribing team
Demonstrate an understanding of ,and contribute to, the workplace vision
Have a proven commitment to improve quality within limitations of service
Monitor professional progress, and with the support of supervisor, develop clear plans to achieve goals and maintain high standards of work
Promote diversity and equality within the workplace and wider community and shall lead by example
Other
Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
Duties may vary from time to time, without changing the general character of the post or the level of responsibility
Job description
Job responsibilities
Main Duties and Responsibilities
Proactively identify people to support their personalised care requirements, using the available decision support aids.
Telephone triage all incoming referrals to bring together all of a persons identified care and support needs, and explore their options to meet these via a single personalised care and support plan, or seamlessly refer cases, if necessary, to appropriate professionals.
Help people to manage their needs, answering their queries and supporting them to make appointments or to take up training and employment, and to access appropriate benefits where eligible.
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the Patient Activation Measure.
Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision making conversation.
Ensure that people have good quality information to help them make choices about their care,
Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame
To be the first point of contact for GP practices, MDT and Social Prescribing Link Workers, as well as a direct link for the wider system across the city.
Support the identification of patients for inclusion in MDTs within PCNs.
Support the collection of patient data for analysis of outcome measure for service interpretation and growth
Education
Promote social prescribing across the PCN, Health & Social Care professionals and the wider system, including its role in self-management, addressing health inequalities and the wider determinants of health.
Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health access and outcomes and enable a holistic approach to care.
Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals.
Referrals
Receive and action referrals for social prescriptions via agreed systems.
Manage and prioritise referrals appropriately.
Redirect referrals, using the agreed protocols, to more appropriate Link workers or agencies.
Be proactive in developing strong links with all local agencies to encourage referrals.
Support referral agencies to provide appropriate information about the person they are referring.
Provide appropriate monitoring and review of referrals received and feedback to referral agencies.
Adhere to data protection legislation and data sharing agreements.
Personalised Support
Work collaboratively & be proactive in encouraging equality and inclusion, through connecting with diverse local communities, particularly those communities that statutory agencies may find hard to reach.
Build trust and respect within the wider team, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on community assets.
Be an engaging source of information about health, wellbeing and prevention approaches.
Analyse data outcomes and identify what individuals expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
Follow up with patients to ensure they are happy, able to engage, included and receiving good support.
Support with patient queries where appointed Social Prescribing Link Worker is unavailable and provide cover during annual leave
Undertake patient and provider surveys to support service development
Community Asset Development
Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing.
Support community groups and VCSE organisations to receive referrals
Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of diverse community groups and assets, who promote diversity and inclusion.
Develop supportive relationships with local VCSE organisations, culturally appropriate community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced.
Work collectively with all local partners to ensure community groups are strong and sustainable
Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision.
Collaborative working
As part of the PCN multi-disciplinary team, build close working relationships with staff in GP practices within the local PCN, giving information and feedback on social prescribing.
Work with established VCSE organisations and existing Link Workers to provide a robust and consistent approach to our Sunderland people.
Explore ways of working and share good practice and learning across all social prescribing roles within the system.
Data Collection & Analysis
Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.
Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing.
Analyse types of referrals, cohorts and end points to support identification of gaps in provision and produce documentation for service interpretation.
Proactively identify cohorts of patients, utilising close links with LA, PHE and GP Practices, that may benefit from accessing Social Prescribing Service
Professional Development
Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities.
Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Service Development
Seek regular feedback about the quality of the service and impact of social prescribing on referral agencies.
Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
Contribute to the development of policies and plans relating to equality, diversity and health inequalities.
Leadership
Support the social prescribing team in the development, delivery and education of social prescribing and health coaching, ensuring involvement where value can be added.
Provide administrative and advisory support to the social prescribing team
Demonstrate an understanding of ,and contribute to, the workplace vision
Have a proven commitment to improve quality within limitations of service
Monitor professional progress, and with the support of supervisor, develop clear plans to achieve goals and maintain high standards of work
Promote diversity and equality within the workplace and wider community and shall lead by example
Other
Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
Duties may vary from time to time, without changing the general character of the post or the level of responsibility
Person Specification
Qualifications
Essential
- Demonstrable commitment to personal and professional development
- Proficient in the use of Microsoft Office applications.
Experience
Essential
- Experience of supporting people, their families and carers in a paid or unpaid capacity
- Experience of working in a community setting
- Experience of handling confidential information.
- Experience of collecting and recording information and data
- Ability to identify risk to self and others, Identifying and reporting safeguarding incidents
Desirable
- Experience of working in or with voluntary organisations or groups in a paid or unpaid capacity
- Experience of working collaboratively with different organisations, building trust, confidence and partnerships
- Extensive knowledge of local services within a Sunderland Locality through either living or working within one of the wider Sunderland settings.
- Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work
Skills & Abilities
Essential
- Prioritise and work to deadlines.
- Outstanding organisational skills
- Work effectively and collaboratively as part of a team but also autonomously.
- High level and adaptable communication skills across a range individuals of all ages, backgrounds and cultures with varying social and emotional needs
- Understanding the impact of economic and environmental factors on peoples health and wellbeing
- Promote and maintain good working relationships with a variety of external partners.
- Keep accurate records of discussions and clearly replicate discussions in writing
- Work on own initiative but within constraints of the role
- Understanding of and commitment to equality, diversity and inclusion
- Ability to competently use technology and IT systems including word processing, email and the internet to create simple personalised plans with individuals
Desirable
- Ability to support the development of small voluntary led groups
Disposition
Essential
- Ability to work across multiple sites in the Sunderland area
- Provide motivational coaching with the ability to inspire trust and confidence
- Confident and comfortable with difficult situations
- Patient, friendly and approachable
- Able to work under pressure and emotionally resilient
- Ability to work flexible hours which may include evenings or weekends
- Ability to actively listen, empathise with people and provide non-judgemental support
- Ability to respect and value individual lifestyles, backgrounds and cultures
Other
Essential
- Full, valid driving licence and use of own car.
- Meet Enhanced DBS and Criminal Record checks
Person Specification
Qualifications
Essential
- Demonstrable commitment to personal and professional development
- Proficient in the use of Microsoft Office applications.
Experience
Essential
- Experience of supporting people, their families and carers in a paid or unpaid capacity
- Experience of working in a community setting
- Experience of handling confidential information.
- Experience of collecting and recording information and data
- Ability to identify risk to self and others, Identifying and reporting safeguarding incidents
Desirable
- Experience of working in or with voluntary organisations or groups in a paid or unpaid capacity
- Experience of working collaboratively with different organisations, building trust, confidence and partnerships
- Extensive knowledge of local services within a Sunderland Locality through either living or working within one of the wider Sunderland settings.
- Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work
Skills & Abilities
Essential
- Prioritise and work to deadlines.
- Outstanding organisational skills
- Work effectively and collaboratively as part of a team but also autonomously.
- High level and adaptable communication skills across a range individuals of all ages, backgrounds and cultures with varying social and emotional needs
- Understanding the impact of economic and environmental factors on peoples health and wellbeing
- Promote and maintain good working relationships with a variety of external partners.
- Keep accurate records of discussions and clearly replicate discussions in writing
- Work on own initiative but within constraints of the role
- Understanding of and commitment to equality, diversity and inclusion
- Ability to competently use technology and IT systems including word processing, email and the internet to create simple personalised plans with individuals
Desirable
- Ability to support the development of small voluntary led groups
Disposition
Essential
- Ability to work across multiple sites in the Sunderland area
- Provide motivational coaching with the ability to inspire trust and confidence
- Confident and comfortable with difficult situations
- Patient, friendly and approachable
- Able to work under pressure and emotionally resilient
- Ability to work flexible hours which may include evenings or weekends
- Ability to actively listen, empathise with people and provide non-judgemental support
- Ability to respect and value individual lifestyles, backgrounds and cultures
Other
Essential
- Full, valid driving licence and use of own car.
- Meet Enhanced DBS and Criminal Record checks
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
Sunderland GP Alliance
Address
North East BIC
Wearfield
Sunderland
Tyne and Wear
SR5 2TA
Employer's website
https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)
Employer details
Employer name
Sunderland GP Alliance
Address
North East BIC
Wearfield
Sunderland
Tyne and Wear
SR5 2TA
Employer's website
https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)
For questions about the job, contact:
Date posted
16 September 2024
Pay scheme
Other
Salary
£27,003.42 a year Pro-rata for part-time
Contract
Fixed term
Duration
12 months
Working pattern
Part-time
Reference number
U0012-24-0055
Job locations
North East BIC
Wearfield
Sunderland
Tyne and Wear
SR5 2TA
Supporting documents
Privacy notice
Sunderland GP Alliance's privacy notice (opens in a new tab)