Job summary
Care
coordinators play an important role within a PCN to proactively identify and
work with people, including care home residents, the frail/elderly, people with
learning disabilities/dementia and those with long-term conditions, to provide
coordination and navigation of care and support across health and care
services.
Regis
Healthcare PCN has recently undergone a review and restructure. This role therefore presents an exciting
opportunity to be part of something new and exciting, where you can influence
the shape of care coordination across the PCN.
Interview Details
Please note, should you be successfully shortlisted, interviews are scheduled to take place on 6th December (AM), 7th December (AM) and Wednesday 13th December (All day)
Further information
Flexible working, fixed hours and part time hours considered. Informal visits welcomed, please contact Nicole Watson-Clarke to arrange.
Main duties of the job
Care Coordinators work closely with GPs and Practice teams to manage a
caseload of patients, acting as a central point of
contact to ensure appropriate support is made available to them and their
carers. They focus on what
matters to patients and support them to understand and manage their condition, ensuring their changing
needs are addressed.
Care coordinators review patients needs, help them access the
services and support they require to understand and manage their own health and
wellbeing and work alongside other
personalised care roles (care coordinators, social prescribing link workers and
health and wellbeing coaches) to provide an
all-encompassing approach to personalised care.
About us
IPC is an innovative and ethical company providing high quality, integrated, patient-focused NHS services. We achieve this by harnessing the collective knowledge, skills, experience and energy of our clinicians and staff. If you believe in the importance and effectiveness of providing excellent care where patients need it and would like to apply, we would love to hear from you.
Benefits of applying:
- NHS Pension
- Flexible working
- Full time and Part time hours available
- Possibility of hybrid working
- Peer Support provided regularly (every 6 weeks)
- Clinical Supervision and Support
Regis Healthcare PCN is made up of the following six practices:
- Arundel Surgery
- Avisford Medical Group
- Bersted Green Surgery
- Bognor Medical Practice
- The Croft
- Flansham Park Health Centre
Job description
Job responsibilities
Job Responsibilities - Key Duties
- Improve the care frail
patients receive by coordinating the delivery of their care, proactively
identifying unmet care needs, and preventing unnecessary hospital admissions,
within the frailty LCS framework
- Work with clinical
professionals and patients to bring together all the information about patients
care and support needed to create personalised care and support plans for frail
patients, and review and update these plans at regular intervals. Ensure the
plans are uploaded to relevant online care record.
- When necessary support
patients to navigate the health and care system, by liaising directly with
services such as Proactive care, care home matrons, wheelchair services,
community nurses, eye/ear testing services, occupational therapists or physios,
and dementia services.
- Help patients manage
their needs by answering queries and supporting them to make appointments.
- To
work with other Care Co-ordinators to develop an in-depth knowledge of the
local health and care infrastructure and know how and when to enable people to
access support and services that are right for them.
- Liaise
with the learning disability/dementia lead in each practice to ensure that
patients on these registers receive an annual review in accordance with
protocols and that their review documents are up-to-date.
- Identify patients with
a new cancer diagnosis and work with this cohort of patients to support their
personalised care via provision of cancer support information and the
in-depth cancer care review.
- Support
patients to utilise decision aids in preparation for shared
decision-making conversations and ensure that they, and their
carers/family, have access to good quality written and verbal information
to help them make choices about their care.
- Coordinate annual
Structured Medication Reviews (SMR) with the PCN Pharmacy Team and MOCH
Pharmacists.
- Refer to social
prescribers and wellbeing workers, when a patient is identified as potentially
benefitting from their services.
- Monitor and expedite
referrals to ensure tasks are completed and care is delivered by keeping in
regular contact with patients and their representatives.
- Organise palliative care Gold Standard
Framework meetings, including invitations, minutes and updating patients
records.
- Support the Practice in
achieving its Quality and Outcome Frameworks and other DES/LES specifications.
- Raise
awareness of health promotion, and support the uptake of national screening and
immunisation programmes of identified patient cohorts.
- Assist
with the coordination of the annual flu and Covid vaccination programmes by
gaining consent from patients or their representatives as appropriate, running
searches to help with planning, and entering data on the clinical system.
- Promote carer awareness
act as a Carers Champion.
- They are skilled in
personalised conversations, assessing peoples needs, facilitating joint working,
ensuring the effective flow of information, monitoring needs and responding to
change.
Multidisciplinary Working- Support clinical and
social care professionals in coordinating all key activity; including access to
services, Multidisciplinary Team (MDT) meetings, advice and information, and
ensure health and care planning is timely, efficient and patient-centred.
- Support the setting up,
coordination and management of regular multidisciplinary hub meetings,
including but not limited to, frailty and palliative care, to ensure a smooth
and coordinated approach.
- Ensure regular and
consistent communication with referrers regarding patient progress and any
complications or guidance suggested by the MDT.
- Identify
opportunities and gaps in the service and contribute to continuous improvements
to the service and business planning.
- Attend Proactive care
team meetings, and Practice meetings when requested.
- Attend PCN Board
meetings, as required, to provide updates on current work/projects.
- Organise a
weekly/bi-weekly ward round for each care home, as required by the allocated
Practice, to obtain relevant information, such as new hospital attendances,
falls, medication and updates regarding residents approaching end of life.
Ensure information gathered from the ward round is documented on the patients
clinical records.
- Organise
monthly care homes education meetings to discuss key topics including, but not
limited to; ReSPECT Forms, Proxy Access, New Care Home Resident forms,
Covid/flu vaccinations and consent.
Other Duties- Contribute
to the development of policies and plans relating to equality, diversity and
reduction of health inequalities.
- Work in accordance with
the Practices and PCNs policies and procedures.
- Care co-ordinators
focus delivery of the comprehensive model to reflect local priorities, health
inequalities or population health management risk stratification. This is a developmental
role and requires a flexible approach and an ability to accept a changing
remit.
Job description
Job responsibilities
Job Responsibilities - Key Duties
- Improve the care frail
patients receive by coordinating the delivery of their care, proactively
identifying unmet care needs, and preventing unnecessary hospital admissions,
within the frailty LCS framework
- Work with clinical
professionals and patients to bring together all the information about patients
care and support needed to create personalised care and support plans for frail
patients, and review and update these plans at regular intervals. Ensure the
plans are uploaded to relevant online care record.
- When necessary support
patients to navigate the health and care system, by liaising directly with
services such as Proactive care, care home matrons, wheelchair services,
community nurses, eye/ear testing services, occupational therapists or physios,
and dementia services.
- Help patients manage
their needs by answering queries and supporting them to make appointments.
- To
work with other Care Co-ordinators to develop an in-depth knowledge of the
local health and care infrastructure and know how and when to enable people to
access support and services that are right for them.
- Liaise
with the learning disability/dementia lead in each practice to ensure that
patients on these registers receive an annual review in accordance with
protocols and that their review documents are up-to-date.
- Identify patients with
a new cancer diagnosis and work with this cohort of patients to support their
personalised care via provision of cancer support information and the
in-depth cancer care review.
- Support
patients to utilise decision aids in preparation for shared
decision-making conversations and ensure that they, and their
carers/family, have access to good quality written and verbal information
to help them make choices about their care.
- Coordinate annual
Structured Medication Reviews (SMR) with the PCN Pharmacy Team and MOCH
Pharmacists.
- Refer to social
prescribers and wellbeing workers, when a patient is identified as potentially
benefitting from their services.
- Monitor and expedite
referrals to ensure tasks are completed and care is delivered by keeping in
regular contact with patients and their representatives.
- Organise palliative care Gold Standard
Framework meetings, including invitations, minutes and updating patients
records.
- Support the Practice in
achieving its Quality and Outcome Frameworks and other DES/LES specifications.
- Raise
awareness of health promotion, and support the uptake of national screening and
immunisation programmes of identified patient cohorts.
- Assist
with the coordination of the annual flu and Covid vaccination programmes by
gaining consent from patients or their representatives as appropriate, running
searches to help with planning, and entering data on the clinical system.
- Promote carer awareness
act as a Carers Champion.
- They are skilled in
personalised conversations, assessing peoples needs, facilitating joint working,
ensuring the effective flow of information, monitoring needs and responding to
change.
Multidisciplinary Working- Support clinical and
social care professionals in coordinating all key activity; including access to
services, Multidisciplinary Team (MDT) meetings, advice and information, and
ensure health and care planning is timely, efficient and patient-centred.
- Support the setting up,
coordination and management of regular multidisciplinary hub meetings,
including but not limited to, frailty and palliative care, to ensure a smooth
and coordinated approach.
- Ensure regular and
consistent communication with referrers regarding patient progress and any
complications or guidance suggested by the MDT.
- Identify
opportunities and gaps in the service and contribute to continuous improvements
to the service and business planning.
- Attend Proactive care
team meetings, and Practice meetings when requested.
- Attend PCN Board
meetings, as required, to provide updates on current work/projects.
- Organise a
weekly/bi-weekly ward round for each care home, as required by the allocated
Practice, to obtain relevant information, such as new hospital attendances,
falls, medication and updates regarding residents approaching end of life.
Ensure information gathered from the ward round is documented on the patients
clinical records.
- Organise
monthly care homes education meetings to discuss key topics including, but not
limited to; ReSPECT Forms, Proxy Access, New Care Home Resident forms,
Covid/flu vaccinations and consent.
Other Duties- Contribute
to the development of policies and plans relating to equality, diversity and
reduction of health inequalities.
- Work in accordance with
the Practices and PCNs policies and procedures.
- Care co-ordinators
focus delivery of the comprehensive model to reflect local priorities, health
inequalities or population health management risk stratification. This is a developmental
role and requires a flexible approach and an ability to accept a changing
remit.
Person Specification
Experience
Essential
- Experience of working in health, social care or other support roles which are in direct contact with people, families or carers.
- Demonstrable and proven organisational capability in a complex environment.
- Experience of working within a multi-professional team environment.
- Awareness of Data Protection Act and confidentiality.
Desirable
- Experience of working in a care co-ordinator role.
- Experience of working with people who may face health inequalities.
- Experience or training in personalised care and support planning.
- Trained in the use of SystmOne, including running clinical reports.
Additional Criteria
Essential
- Flexibility to work outside core office hours, including extended hours services.
- Ability to work across the locality on a regular basis.
- Meet a Disclosure and Barring Service (DBS) reference standards and criminal record checks.
Desirable
- Hold a valid UK driving license and have access to own transport.
Skills & Knowledge
Essential
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Understanding of, and commitment to, equality, diversity and inclusion.
Desirable
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes.
Personal Qualities and Attributes
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental manner.
- 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 plan, organise and prioritise work, using own initiative. Working under pressure and to deadlines.
- Ability to maintain effective working relationships and to promote collaborative practice with colleagues.
Qualifications
Essential
- Functional Literacy and Numeracy level 2/GCSE Grade A-C, including Math's and English Language.
Desirable
- NVQ level 3 in health and social care related discipline
Person Specification
Experience
Essential
- Experience of working in health, social care or other support roles which are in direct contact with people, families or carers.
- Demonstrable and proven organisational capability in a complex environment.
- Experience of working within a multi-professional team environment.
- Awareness of Data Protection Act and confidentiality.
Desirable
- Experience of working in a care co-ordinator role.
- Experience of working with people who may face health inequalities.
- Experience or training in personalised care and support planning.
- Trained in the use of SystmOne, including running clinical reports.
Additional Criteria
Essential
- Flexibility to work outside core office hours, including extended hours services.
- Ability to work across the locality on a regular basis.
- Meet a Disclosure and Barring Service (DBS) reference standards and criminal record checks.
Desirable
- Hold a valid UK driving license and have access to own transport.
Skills & Knowledge
Essential
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Understanding of, and commitment to, equality, diversity and inclusion.
Desirable
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes.
Personal Qualities and Attributes
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental manner.
- 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 plan, organise and prioritise work, using own initiative. Working under pressure and to deadlines.
- Ability to maintain effective working relationships and to promote collaborative practice with colleagues.
Qualifications
Essential
- Functional Literacy and Numeracy level 2/GCSE Grade A-C, including Math's and English Language.
Desirable
- NVQ level 3 in health and social care related discipline
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.
