Frailty Care Co-ordinator

Job description

Job responsibilities

Job Description

Job Purpose

Care coordination in General Practice is part of an exciting programme of transformation to develop a new model of care which addresses our ambition to deliver a person-centered coordinated care.

Care Coordinators proactively identify and work with specified cohorts of people to support their personalised care requirements, using the available decision support aids and MDTs. They act as the pivotal point of coordination for specified groups of patients and bring together all of a persons identified care and support needs, and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice. This role will initially focus on established patient cohorts but will expand to develop support for our population needing proactive care and integration with our local ICT.

Key Responsibilities

Coordinate and manage regular multidisciplinary hub meetings, for the Whitewater Frailty Team

Manage the appointments of the clinical team.

Develop and coordinate the integrated care team hub and development of a shared caseload between community nursing and PCN link nursing

Proactively identify and work with a cohort of people identified as needing proactive care to support their personalised care requirements, using the available decision support aids

Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance suggested by the MDT

Raise awareness of health promotion and NHS health checks in practices

Support national screening programmes and immunization programmes in support of the identified patient cohort. This may involve going off-site, i.e; to visit Care Homes.

Assist clinicians with the completion of referral forms and monitor referrals to ensure tasks are completed and care delivered by keeping in regular contact

Direct liaison with multi agencies to coordinate care for patients

Refer to PCN social prescribers, health and wellbeing coach and MIND wellbeing workers where a patient is identified as potentially benefitting from this service

To support patient/carer contact roles, and collate patient and carer feedback on their experiences

Support Quality and Outcome Frameworks and other DES/LES specifications with service reporting

Maintain and develop engagement with all practice staff and encourage best practice

Act as the first port of call for patients, in their caseload in relation to their care.

Bring together all of a persons identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP), in line with PCSP best practice

Help people to manage their needs, answering their queries and supporting them to make appointments

Support people to take up training, employment and access appropriate benefits where eligible

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 using 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, alongside working closely with social prescribing link workers and other primary care roles

Support the coordination and delivery of MDTs within PCNs.

Awareness of Safeguarding protocols

This role profile is not exhaustive, and you may be directed to complete other tasks according to the skills and requirements for individual roles. These duties will always be reasonable and deemed within the expectations of your position.

Person Specification

Qualifications

Essential

• Completed or able to complete Care-Co-ordinator Training
• Demonstrable commitment to professional and personal
• development

Desirable

• ECDL or equivalent
• Diploma/ HNC level (or relevant experience)
• NVQ Level 2 Business Administration (or relevant experience)
• Training in motivational coaching and interviewing or equivalent

Experience

Essential

• Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work)
• Experience of data collection and providing monitoring information to assess the impact of services
• Experience of partnership/collaborative working and of building relationships across a variety of organisations
• Experience of working with or in general practice
• Working in a multi-disciplinary setting where influence and negotiation is required
• Knowledge/familiarity with medical terminology

Desirable

• Experience of supporting people, their families and carers in a related role (including unpaid work)
• Experience in use of databases
• Vulnerable adults awareness and Safeguarding awareness
• Experience of care of the elderly

Personal Qualities & Attributes

Essential

• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• Able to work as part of a team
• Able 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, partner agencies and stakeholders.
• Ability to identify risk and assess/manage risk when working with individuals
• Excellent negotiating skills
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues in PGPA, PCN and the wider system
• Demonstrates personal accountability, emotional resilience and works well under pressure
• Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
• Access to own transport and ability to travel across the locality on a regular basis
• Continued commitment to improve skills and ability in new areas of work

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

Whitewater Health

Address

Reading Road

Hook

Hampshire

RG27 9ED

Employer's website

https://www.hooksurgery.nhs.uk/ (Opens in a new tab)