Job summary
The Care Coordinator role is seen as a critical and evolving
post to support the multi-disciplinary teams (MDTs) within the PCN to deliver
effective, co-ordinated and personalised care for patients in care homes and
for a cohort of elderly and frail patients.
Care Coordinators play an important role within a PCN to
proactively identify and work with people, including the frail/elderly and
those with long-term conditions, to provide coordination and navigation of care
and support across health and care services.
They 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 people and their carers; supporting
them to understand and manage their condition and ensuring their changing needs
are addressed.
Main duties of the job
- Proactively identify and work with a cohort of patients to support their personalised care requirements
- Provide coordination and navigation support using digital tools to help patients access appropriate services
- Develop and maintain personalised care and support plans based on an individuals needs and what matters to them.
- Promote preventative health care and continuity of care.
About us
York City PCN is delighted to offer a great opportunity for
a highly motivated Care Coordinator who wishes to develop their career within
an exceptional primary care environment.
York City Primary Care Network (PCN) are two innovative GP
practices Jorvik Gillygate and Dalton Terrace which are both situated within
the York ring road
Our fantastic clinical team includes GPs, ACPs, Pharmacists,
Physician Associates, Nurses, HCAs and Social Prescribes.
Job description
Job responsibilities
- Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
- Help people to manage their needs by providing a contact to ensure that people have good quality written or verbal information to help them make choices about their care.
- Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
- Support the coordination and delivery of multidisciplinary teams with the PCN.
- Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations.
- Take referrals or proactively identify people who could benefit from support through care coordination.
- Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
- 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.
- Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.
- Support people to develop and implement personalised care and support plans.
- Review and update personalised care and support plans at regular intervals.
- Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records.
- Make and manage appointments for patients, related to primary care.
- Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.
- Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
- Identify when action or additional support is needed, alerting a named contact in addition to relevant professionals, and highlighting any safety concerns.
- Record what interventions are used to support people, and how people are developing on their health and care journey.
- Work with your supervising GP to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.
- Involved in one-to-one meetings with line manager regularly to discuss targets and outcomes achieved.
- Act as a champion for personalised care and shared decision making within the PCN.
- Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
- Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities.
- Adhere to organisational, practices and PCN policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Job description
Job responsibilities
- Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
- Help people to manage their needs by providing a contact to ensure that people have good quality written or verbal information to help them make choices about their care.
- Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
- Support the coordination and delivery of multidisciplinary teams with the PCN.
- Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations.
- Take referrals or proactively identify people who could benefit from support through care coordination.
- Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
- 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.
- Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.
- Support people to develop and implement personalised care and support plans.
- Review and update personalised care and support plans at regular intervals.
- Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records.
- Make and manage appointments for patients, related to primary care.
- Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.
- Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
- Identify when action or additional support is needed, alerting a named contact in addition to relevant professionals, and highlighting any safety concerns.
- Record what interventions are used to support people, and how people are developing on their health and care journey.
- Work with your supervising GP to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.
- Involved in one-to-one meetings with line manager regularly to discuss targets and outcomes achieved.
- Act as a champion for personalised care and shared decision making within the PCN.
- Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
- Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities.
- Adhere to organisational, practices and PCN policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Person Specification
Qualifications
Essential
- GCSE grade A to C in English and Maths
Desirable
- Qualified to NVQ level 2 in Health and Social Care
Experience
Essential
- Driving Licence
- Administrative experience
- Experience of working with the general public
Desirable
- Experience of working in primary care
- Experience of working in a health care setting
Knowledge and skills
Essential
- Excellent communication skills (written and oral)
- Strong IT skills (generic)
- Clear, polite telephone manner
- Effective time management (Planning & Organising)
- Ability to work as a team member and autonomously
- Good interpersonal skills
- Problem solving & analytical skills
- Ability to follow policy and procedure
Desirable
- Competent in the use of Office and Outlook
- Systmone user skills
Person Specification
Qualifications
Essential
- GCSE grade A to C in English and Maths
Desirable
- Qualified to NVQ level 2 in Health and Social Care
Experience
Essential
- Driving Licence
- Administrative experience
- Experience of working with the general public
Desirable
- Experience of working in primary care
- Experience of working in a health care setting
Knowledge and skills
Essential
- Excellent communication skills (written and oral)
- Strong IT skills (generic)
- Clear, polite telephone manner
- Effective time management (Planning & Organising)
- Ability to work as a team member and autonomously
- Good interpersonal skills
- Problem solving & analytical skills
- Ability to follow policy and procedure
Desirable
- Competent in the use of Office and Outlook
- Systmone user skills
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.
