Job summary
The Enhanced
Health in Care Homes (EHCH) Care Coordinator role is a crucial and evolving
post to support multi-disciplinary working across Deal and Sandwich Primary
Care Network (PCN) for people living in nursing and residential homes. The post
holder will coordinate care planning and support for residents, proactively
identifying their personalised care needs, using decision support aids as
required. The EHCH Care Coordinator will bring together the patients
identified care and support needs and explore with them options to meet their
needs, recording them in a single personalised care and support plan (PCSP). This
will also include undertaking basic physical health monitoring to ensure
holistic assessment including blood pressure, oxygen saturation, respiratory
rate, weight, phlebotomy etc.
Alongside
the above, the post holder will undertake admin coordination tasks to support
the team to ensure ward rounds, MDT meetings and care plans all happen and are
actioned within a timely manner to support the delivery of high quality care.
We
are looking for someone who is passionate about delivering person-centered
care, has a professional approach to their work, who is caring, dedicated and
compassionate to the needs of the patient. The right candidate requires excellent
written and verbal communication skills as well as having strong time and case
management abilities.
Main duties of the job
Support the PCN in bringing
together all of a patients identified care and support needs and explore
options to meet these within a single PCSP, in line with best practice and
based on what matters to the patient
Work closely with
patient families and or advocates to enable them to support their loved ones in
decision making and personalised care planning
Provide vital signs
monitoring such as blood pressure, oxygen saturation, respiratory rate, weight,
phlebotomy etc.
Liaise with key
stakeholders as needed for the collective benefit of the patient
Provide accurate,
impartial information, support and guidance to patients and their carers to
enable them to make choices about their care
Provide coordination
and navigation for patients and their carers across health and social care
services
Build a long term
working relationship with care homes
Review care home ward
round information appropriate to skill level and support data entry for the
team accordingly
This is a new role and we anticipate that it will evolve and develop over time. The scope of the role will be wide and varied, and the post holder must be adaptable to meet the demands of a changing environment.
About us
Deal & Sandwich Primary Care Network (PCN) comprises 5
GP practices: Balmoral Surgery, Cedars Surgery, Manor Road Surgery, Sandwich
Medical Practice and St Richards Road Surgery, with a combined list size of
around 48,000 patients. The practices work together to deliver care and support
through new and innovative ways which enables our patients to live healthy and
fulfilling lives.
Job description
Job responsibilities
The attached job
description and person specification gives you all the information you need
about this role. Please look carefully at the criteria in the person
specification and tell us what you have done that shows you meet this.
Personalised Care and Support
Planning (PCSP)
The EHCH Care Home Coordinator will
take responsibility for bringing together all of a patients identified care
and support needs, and explore options to meet these within a single
personalised care and support plan (PCSP), in line with PCSP best practice and
based on what matters to the patient. The plan developed will respect the individuals
needs and wishes in considering their current and anticipatory care needs and
be developed in communication with families, carers and other members of the
MDT where indicated. The post holder will work closely with patient families
and / or advocates to enable them to support their loved ones in decision
making and personalised care planning. This will include ensuring they have
good quality information to enable them to make choices about their care.
The EHCH Care Home Coordinator will
ensure each patient has a personalised care and support plan completed informed
through team data input using appropriate coding. The post holder will also
liaise with colleagues to identify those patients who would benefit from having
a review of their personalised care plan in response to an increase in their
level of frailty, their expressed wishes or in liaison with their advocate /
family to ensure equity of access to personalised care planning for those who
have reduced mental capacity.
Clinical interventions
The EHCH Care Home Coordinator will
provide vital signs monitoring such as blood pressure, oxygen saturation,
respiratory rate, weight, phlebotomy etc. and will assist patients and carers
in managing their own needs, answering their queries and supporting them to
address their needs. The post holder will provide accurate, impartial
information, support and guidance to patients and their carers to ensure they
have high quality health information.
The EHCH Care Home Coordinator will
work within their skills remit and closely with the team and care homes to
identify patients who are required to be seen as part of the care home ward
round. This will include receiving and collating information from transfers of
care including hospital admissions and discharges, new resident admissions, out
of hours calls etc. for care home residents. The post holder will identify and
process any safeguarding and quality of care issues and refer as appropriate to
ensure that the patients' welfare is protected.
Care Coordination
The EHCH Care Home Coordinator will
proactively work in partnership with local providers as needed for the
collective benefit of the patient to enable care coordination of high quality
personalised and proactive care. This will include liaising with patients or
their family / carers, care home staff, GPs, practice staff, community nursing
staff, PCN multidisciplinary team and other support staff from within the PCN
practices or from other provider organisations.
The EHCH Care Home Coordinator will
build long term working relationships with the care homes through ensuring
timely assessment of residents and development of care plans and providing
coordination and navigation for patients and their carers across health and
social care services.
Job description
Job responsibilities
The attached job
description and person specification gives you all the information you need
about this role. Please look carefully at the criteria in the person
specification and tell us what you have done that shows you meet this.
Personalised Care and Support
Planning (PCSP)
The EHCH Care Home Coordinator will
take responsibility for bringing together all of a patients identified care
and support needs, and explore options to meet these within a single
personalised care and support plan (PCSP), in line with PCSP best practice and
based on what matters to the patient. The plan developed will respect the individuals
needs and wishes in considering their current and anticipatory care needs and
be developed in communication with families, carers and other members of the
MDT where indicated. The post holder will work closely with patient families
and / or advocates to enable them to support their loved ones in decision
making and personalised care planning. This will include ensuring they have
good quality information to enable them to make choices about their care.
The EHCH Care Home Coordinator will
ensure each patient has a personalised care and support plan completed informed
through team data input using appropriate coding. The post holder will also
liaise with colleagues to identify those patients who would benefit from having
a review of their personalised care plan in response to an increase in their
level of frailty, their expressed wishes or in liaison with their advocate /
family to ensure equity of access to personalised care planning for those who
have reduced mental capacity.
Clinical interventions
The EHCH Care Home Coordinator will
provide vital signs monitoring such as blood pressure, oxygen saturation,
respiratory rate, weight, phlebotomy etc. and will assist patients and carers
in managing their own needs, answering their queries and supporting them to
address their needs. The post holder will provide accurate, impartial
information, support and guidance to patients and their carers to ensure they
have high quality health information.
The EHCH Care Home Coordinator will
work within their skills remit and closely with the team and care homes to
identify patients who are required to be seen as part of the care home ward
round. This will include receiving and collating information from transfers of
care including hospital admissions and discharges, new resident admissions, out
of hours calls etc. for care home residents. The post holder will identify and
process any safeguarding and quality of care issues and refer as appropriate to
ensure that the patients' welfare is protected.
Care Coordination
The EHCH Care Home Coordinator will
proactively work in partnership with local providers as needed for the
collective benefit of the patient to enable care coordination of high quality
personalised and proactive care. This will include liaising with patients or
their family / carers, care home staff, GPs, practice staff, community nursing
staff, PCN multidisciplinary team and other support staff from within the PCN
practices or from other provider organisations.
The EHCH Care Home Coordinator will
build long term working relationships with the care homes through ensuring
timely assessment of residents and development of care plans and providing
coordination and navigation for patients and their carers across health and
social care services.
Person Specification
Qualifications
Essential
- NVQ Level 3 in a health or social care related discipline (or equivalent experience)
- GCSE grade A to C (9-4) in English and Maths or equivalent
- Demonstrate commitment to professional and personal development
Desirable
- Completion of care certificate
Knowledge and skills
Essential
- Understanding of the support requirements of those who reside within residential and nursing homes including basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social
- Understanding of medical terminology around frailty, population health management and long term conditions
- Excellent communication skills (written and oral)
- Ability to actively listen, empathise with people and provide person-centered support in a non-judgmental way
- Excellent organisational and administrative skills, including use of MS Office applications and Outlook
- Willingness to work flexibly, demonstrating problem solving skills and an ability to respond to sudden unexpected demands
- Attention to detail, especially when recording patients information and interventions
- Ability to be self-motivated and proactive
Desirable
- Knowledge of primary care networks and collaborative ways of working
- This role will be based in Deal and Sandwich but will involve travel between care homes, practices and community venues so a full driving license is desirable, mileage is claimable
Experience
Essential
- Minimum of 2 years experience of working as a Health Care Assistant / Nurse Associate or equivalent experience
- Experience of working in health, social care and other support roles in direct contact with people, families and carers
- Experience in performing and recording basic health measures i.e. blood pressure, oxygen saturation, respiratory rate, weight, phlebotomy etc.
- Experience of dealing with confidential and sensitive matters
- Experience of working independently and organising and prioritising own workload
Desirable
- Experience of working with older, vulnerable patients or adults with complex needs
- Experience of EMIS
Person Specification
Qualifications
Essential
- NVQ Level 3 in a health or social care related discipline (or equivalent experience)
- GCSE grade A to C (9-4) in English and Maths or equivalent
- Demonstrate commitment to professional and personal development
Desirable
- Completion of care certificate
Knowledge and skills
Essential
- Understanding of the support requirements of those who reside within residential and nursing homes including basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social
- Understanding of medical terminology around frailty, population health management and long term conditions
- Excellent communication skills (written and oral)
- Ability to actively listen, empathise with people and provide person-centered support in a non-judgmental way
- Excellent organisational and administrative skills, including use of MS Office applications and Outlook
- Willingness to work flexibly, demonstrating problem solving skills and an ability to respond to sudden unexpected demands
- Attention to detail, especially when recording patients information and interventions
- Ability to be self-motivated and proactive
Desirable
- Knowledge of primary care networks and collaborative ways of working
- This role will be based in Deal and Sandwich but will involve travel between care homes, practices and community venues so a full driving license is desirable, mileage is claimable
Experience
Essential
- Minimum of 2 years experience of working as a Health Care Assistant / Nurse Associate or equivalent experience
- Experience of working in health, social care and other support roles in direct contact with people, families and carers
- Experience in performing and recording basic health measures i.e. blood pressure, oxygen saturation, respiratory rate, weight, phlebotomy etc.
- Experience of dealing with confidential and sensitive matters
- Experience of working independently and organising and prioritising own workload
Desirable
- Experience of working with older, vulnerable patients or adults with complex needs
- Experience of EMIS
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.