Job summary
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.
Main duties of the job
Coordinate and support the delivery of proactive, person-centred care for individuals living with frailty within the Primary Care Network (PCN). Organise and manage regular multidisciplinary team (MDT) hub meetings for the Whitewater Frailty Team and coordinate clinical team appointments, supporting the development of an integrated care hub and shared caseload across community and PCN nursing teams.
Identify and work proactively with a cohort of patients requiring coordinated frailty care, supporting personalised care planning and ensuring their health and wellbeing needs are addressed through a single Personalised Care and Support Plan (PCSP). Act as a key point of contact for patients and carers, providing guidance, answering queries, and supporting access to appointments, services and appropriate benefits where eligible.
Facilitate communication between clinicians, referrers and partner organisations, ensuring timely updates on patient progress and outcomes. Liaise with community services, social prescribers, health and wellbeing coaches, MIND wellbeing workers and other agencies to coordinate holistic care and ensure appropriate referrals and follow-up.
Support health promotion initiatives including NHS Health Checks, national screening and immunisation programmes, including outreach activity such as care home visits. Assist clinicians with referrals, track progress of care plans and ensure tasks are completed.
About us
Whitewater Health is a progressive and patient-focused GP practice located in Northeast Hampshire, operating across two sites in Hook and Hartley Wintney. We serve a diverse and growing population of approximately 18,000, providing high-quality, accessible healthcare with a strong emphasis on continuity of care, innovation, and collaborative working.
As a training and teaching practice, we are proud to support the development of clinicians at all stages of their careers, fostering a culture of learning, reflection, and clinical excellence. Our multidisciplinary team includes GPs, ACP's, Frailty team, practice nurses, HCAs, pharmacists, social prescribers, physiotherapists, and mental health practitioners, working together to deliver holistic care tailored to the needs of our patients.
We are rated Good by the Care Quality Commission and are actively engaged in quality improvement initiatives across the practice and wider Primary Care Network. Our commitment to staff wellbeing, professional development, and inclusive practice makes Whitewater Health a rewarding and supportive environment in which to thrive.
Job description
Job 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
Job description
Job 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
Person Specification
Qualifications
Essential
- GCSE grade A to C in English and Maths
- Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work)
- Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports
- 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.
- Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
Desirable
- ECDL or equivalent
- Diploma/ HNC level (or relevant experience)
- NVQ Level 2 Business Administration (or relevant experience)
Experience
Essential
- Experience of dealing with vulnerable patients
- Experience of working with healthcare professionals and or previous experience in the NHS, social care or relevant field
Person Specification
Qualifications
Essential
- GCSE grade A to C in English and Maths
- Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work)
- Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports
- 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.
- Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
Desirable
- ECDL or equivalent
- Diploma/ HNC level (or relevant experience)
- NVQ Level 2 Business Administration (or relevant experience)
Experience
Essential
- Experience of dealing with vulnerable patients
- Experience of working with healthcare professionals and or previous experience in the NHS, social care or relevant field
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.
