Care Coordinator

Job description

Job responsibilities

• Key responsibilities

Provide coordination and navigation, and support referrals for people and their carers across health and care services, working closely with community services and other members of the Primary Care team; helping to ensure patients receive a joined-up service and the most appropriate support.

Manage a caseload of referred patients approaching End of Life, and proactively identify a cohort of people in need of anticipatory care, using local knowledge and population health intelligence in the Virtual White Board tool.

Support the organisation, coordination and delivery of multidisciplinary teams (MDTs) with the PCN

Attend the MDTs and be the key person for ensuring regular attendance from nominated representatives or their deputies for each service

Ensure MDT actions are recorded appropriately and followed-up within the defined timescales agreed at the MDT meetings

Improve continuity of care by acting as a point of contact for patients, families and professionals, such as MDT members and in-reach specialists

Bring together a person's identified care and support needs and explore their options to meet these in a single personalised care and support plan

Ensure that people have good quality information to help them make choices about their care and structure conversations using a coaching approach

Assist people to access self-management education courses, peer support and interventions that support them in their health and wellbeing

Explore and assist people to access personal health budgets, where appropriate

Person Specification

Experience

Essential

• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
• Ability to identify risk and assess / manage risk when working with individuals
• Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• Ability to demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• High level of written and verbal communication skills
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
• Proficient in MS Office and web-based services
• Experience of supporting people, their families and carers in a related role
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Ability to recognise and work within limits of competence and seek advice when needed
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Meets DBS reference standards and criminal record checks
• Willingness to work flexible hours when required to meet work demands

Desirable

• Ability to provide motivational coaching to support behaviour change
• NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
• 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)
• Experience or training in personalised care
• and support planning
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Knowledge of how the NHS works, including primary care and PCNs
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
• Access to own transport
• Ability to travel across the locality on a regular basis

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

Underwood Surgery

Address

The Wilson Health Centre

236 Prestbury Road

Cheltenham

Gloucestershire

GL52 3EY

Employer's website

https://underwoodsurgery.co.uk/ (Opens in a new tab)