Job responsibilities
A Care Home Care coordinator helps to improve the continuity of care by acting as a pointof contact for residents, families and professionals who visit, or work in the care home,such as MDT members and in-reach specialists. They will also lead the coordination ofthe Care Home MDT and the weekly care home round, this through identification of people in need of review and/or discussion.
Care coordinators provide extra time, capacity and expertise to support individuals in preparing for, or in following-up clinical conversations they have with primary care professionals. They will work closely with the Care Home Leads and other primary care professionals within the PCN to identify and manage a caseload of identified care homes; making sure that appropriate support is made available to the staff and their residents; and ensuring that their changing needs are addressed. They focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health. This role is designed to improve communication processes between Primary Care and Care Home staff, providing on-going support to prevent inappropriate G.P. contacts and/or hospital admissions.
The Enhanced Health in Care Homes Framework is a new initiative and as such this role will adapt and evolve, therefore for the post holder must have a positive and adaptability towards change and service development.
Post holders will need to demonstrate flexibility and adaptability to working in a dynamic and busy environment
Key Role Requirements:
* Proactively identify and work with a group of care homes to support personalised care requirements for their residents, using the available decision support aids.
* Help people to manage their needs, answering their queries and supporting them to make referrals into the Care Home MDT or escalation of need to the Care Home Clinical Team.
* 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,
* Support people to understand their level of knowledge, skills and confidence(their Activation level) when engaging with their health and wellbeing, including through use of the Patient Activation Measure.
* Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
* Explore and assist people to access personal health budgets where appropriate.
* Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
* Lead the coordination and delivery of the Care Home MDTs within the PCN.
* Demonstrate flexibility and adaptability to working in a dynamic environment. To liaise and work with multiple services and external stakeholders, acting as a conduit for information sharing and communication between the CCG, GPs, practices, KCHFT, Social Care Teams, KCC Commissioners, patients and voluntary sector.
* Have a sound knowledge of health and social care policy, together with local services and health promotion initiatives, that will enable the safe transfer of clients between different provider services, and the integration of services from different providers where indicated
* Support the continued development and coordination of an Integrated Health and Social Care Multi-Disciplinary team meetings approach across the Primary Care Network. This will provide a coordinated response to referrals from GPs and health and social care teams.
* The PCN Community care Co-ordinators role is critical in ensuring that patients are signposted to the correct health, social or voluntary agency in a timely manner.
Communication and Relationship Skills
* To provide a single point of contact for GPs and the PCN to support them with investigating service user/patient case history to improve coordination of care
* To coordinate and attend Inter-professional meetings, providing appropriate feedback.
* Record, minute and monitor outcomes and actions from the MDTs as required within each PCN.
* To take Health and Social Care referral information according to required process e.g. via SBAR which may involve carrying out telephone or face to face contact (if NVQ trusted assessor if not to access training) assessments and receiving referrals from other agencies and professionals on a daily basis.
* Develop and maintain effective working relationships with integrated teams including long term and practice linked teams, GP practices and other agencies to ensure that service users receive a consistent, integrated response to all contacts/referrals.
* To have advanced communication skills, being able to discuss difficult and possibly contentious issues with patients, relatives and health professionals.