Care Coordinator (Frailty)

Job description

Job responsibilities

Proactively identify and work with cohorts of patients to deliver personalised care.

Support patients to utilise decision making tools to prepare for shared decision-making conversations.

Working holistically, bring together their identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP).

Help people to manage their needs by answering their queries, making and managing appointments, providing good quality written or verbal information to inform decision making and enhancing their knowledge, skills and confidence.

Support people to take up employment and training and to access appropriate benefits through referral to the Social Prescribing Link Workers.

Connect patients with tools to support them, such as self-management education, peer support and the adoption of healthy behaviours.

Provide co-ordination and navigation for people and their carers across health and care services, working closely with the Social Prescribing Link Worker, Health and Wellbeing Coaches and other health professionals.

Support the co-ordination of MDTs across the PCN.

Raise awareness of the benefits of shared decision making and decision support tools, how to use these and how to identify patients who may benefit from this approach.

Ensure all VCSE organisations have appropriate safeguarding procedures in place and are genuine opportunities for patients to develop a sense of belonging, build knowledge, skills, and confidence.

Discuss concerns with a relevant GP to ensure safeguarding procedures are followed appropriately.

Person Specification

Qualifications

Essential

• Good standard of education.
• To understand and in practice could apply Caldicott Principles, Data Protection Act 2018 and appropriately protect an individuals personal data, disclosing where appropriate only

Desirable

• NVQ level 2 in Health & Social Care
• Enrolled/in progress/qualified from appropriate training as set out by the Personalised Care Institute (PCI) or willing to undertake

Experience

Essential

• Awareness of the wider determinants of health and its impact
• Understands the needs of older people/adults with disabilities/long terms conditions particularly in relation to promoting their independence
• Organised and with good attention to detail
• Ability to prioritise workload.
• To deliver outcomes based on set targets
• Liaise with other colleagues to promote the success of the PCN and its Partner organisations in primary care
• Work to perpetuate a culture that is transparent and open
• Could collate data and use tools to demonstrate the impact of services
• Recognises and works within limits of competence, seeking advice when needed
• Awareness of and has well-developed IT skills to facilitate quick and confident learning of new systems to support the management of patients in a primary care setting (including Microsoft packages)
• Working well with others to deliver goals
• Being motivated to deliver excellent services to support Primary Care in our region

Desirable

• Experience of working in multidisciplinary professional team environments
• Experience or training in personalised care and support planning
• Working in Primary Care/General Practice
• Experience of working directly in a care coordinator role, in adult health, social care, learning support or public health/health improvements

Other

Essential

• Drive and have access to transport to attend visits or sites across the PCN, this may include home visits

Behaviours

Essential

• Communicates with colleagues well to ensure the smooth delivery of services
• Proactively supports others to deliver team objectives
• Takes responsibility for actions and looks to enhance the service and its reputation in all activities undertaken
• Actively engages with building personal capacity and resilience

Desirable

• IT 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.

Employer details

Employer name

Panacea Collaborative

Address

65-69 Stirling Street

Grimsby

North East Lincolnshire

DN31 3AE

Employer's website

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