Job summary
Care coordinators play an important role within a Practice to proactively identify and work with people, to provide coordination and navigation of care and support across health and care services.
They work closely with GPs and practice teams to manage a caseload of patients and projects, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
The Care Coordinator will also work on supporting our prescribing team transformation which aims make the prescription process more effective for patients and clinicians.
The successful candidate will be caring, dedicated, reliable and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing high quality support.
Main duties of the job
Support the Prescribing Transformation work
Work with people, their families and carers to improve 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.
Provide coordination and navigation for people and their carers across health and care services, working closely with the Surgery team, social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined up service and the most appropriate support.
Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
Explore and assist people to access a personal health budget where appropriate.
Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours;
Identify unpaid carers and help them access services to support them;
Conduct follow-ups on communications from out of hospital and in-patient services;
Support clinical admin for GP team, Pharmacy Team and Health Navigation Team.
This is not an exhaustive list
About us
CKMP is at the vibrant & colourful heart of Bristol's inner city, serving a population from all corners of the world and from all walks of life.
Our largest ethnic minority groups come from the Caribbean, the Asian subcontinent and Somalia.
We serve patients who may be homeless, struggling with alcohol or drugs, and seeking help to begin piecing life together; at the other end of the spectrum we serve patients who are settled, doing well in life, and who seek help to ensure they remain in the very best of health.
About BrisDoc:
BBrisdoc is a proud provider of NHS Healthcare. We have been delivering 'patient care, by people who care' for over twenty years.
We're a Social Enterprise and an Employee-Owned Business. This means the decisions we make are for the good of our patients, workforce, and wider community. This involves prioritising the health of our patients, protecting our environment, and improving the social and economic status of our population.
By joining BrisDoc, you will be part of an innovative organisation that prides itself on being a fantastic place to work; somewhere that you will feel valued, supported, developed and part of a family. We strive to make sure every member of the team feels proud of the work they do and the service that we offer.
Job description
Job responsibilities
Key Tasks
1.Support with Prescribing Transformation
a. Attending project meetings
b. Support the pharmacy team with administrative help
c. Help to identify effective ways of working
d. Assist in managing the Project
2. Enable access to personalised care and support
a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination;
b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs;
c. Support people to develop and implement personalised care and support plans;
d. Review and update personalised care and support plans at regular intervals;
e. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes;
f. Where a personal health budget is an option, to work with the person and the local CCG team to provide advice and support as appropriate.
3. Coordinate and integrate care
a. Help people transition seamlessly between services and support them to navigate through the health and care system;
b. Refer onwards to social prescribing link workers and health and wellbeing coaches where required;
c. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;
d. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate;
e. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
Job description
Job responsibilities
Key Tasks
1.Support with Prescribing Transformation
a. Attending project meetings
b. Support the pharmacy team with administrative help
c. Help to identify effective ways of working
d. Assist in managing the Project
2. Enable access to personalised care and support
a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination;
b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs;
c. Support people to develop and implement personalised care and support plans;
d. Review and update personalised care and support plans at regular intervals;
e. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes;
f. Where a personal health budget is an option, to work with the person and the local CCG team to provide advice and support as appropriate.
3. Coordinate and integrate care
a. Help people transition seamlessly between services and support them to navigate through the health and care system;
b. Refer onwards to social prescribing link workers and health and wellbeing coaches where required;
c. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;
d. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate;
e. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
Person Specification
Qualifications and Training
Essential
- GCSE Grade C or above (equivalent) in English and Maths
Desirable
- NVQ Level 3 in Adult Care - advanced level or equivalent qualifications or working towards
Knowledge and Experience
Essential
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
Desirable
- Experience of working directly in a Care Coordinator role, adult health and social care, learning support or public health/health improvement
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
Person Specification
Qualifications and Training
Essential
- GCSE Grade C or above (equivalent) in English and Maths
Desirable
- NVQ Level 3 in Adult Care - advanced level or equivalent qualifications or working towards
Knowledge and Experience
Essential
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
Desirable
- Experience of working directly in a Care Coordinator role, adult health and social care, learning support or public health/health improvement
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
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.
