Job summary
The Care Coordinator role is seen as a critical and evolving post to support the Enhanced Health in Care Homes (EHCH) Multi-Disciplinary Teams within the locality to deliver effective, co-ordinated care for vulnerable and frail adults, particularly those at high risk of a hospital emergency admission, ED attendances or out of hours care. Proactively coordinate personalised care and support planning for the most vulnerable people in the community, including the frail/elderly and those living with other long-term health conditions.
To meet with people, families and carers (in practice, in their home and in other community settings) to co-ordinate their care, review their needs and help them access the services and support they require, assisting them to understand and manage their own health and wellbeing referring to other professionals where appropriate.
Main duties of the job
Act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
To support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.
About us
The South Devon Primary Care Network is an exciting collaboration between 5 GP Surgeries: Dartmouth Medical Practice, Chillington Health Centre, Modbury Health Centre, Norton Brook Health Centre and Redfern Health Centre.
The PCN surgeries look after people in their towns as well as leafy rural Devon in the South Hams. They have a shared patient population of just over 30,000 patients.
Job description
Job responsibilities
The South Hams is a region of rural and coastal Devon, much of which is
designated as an Area of Outstanding Natural Beauty with some of the most
beautiful beaches and coastal walks, a great place for family and friends to
enjoy. It has a mild climate and is a wonderful place to live and work. It has
been long recognised as a 'foodies' paradise with many niche and high-end
producers servicing fantastic local restaurants, farmers markets and celebrated
food festivals.
Working for the South Hams Primary Care Network you will have the
opportunity of flexible working patterns with support and encouragement to
learn by offering training programs, mentoring and tuition assistance for
work-related courses. You will be part of a team network and where you will
feel you are making a difference. We offer an NHS pension scheme and excellent
annual leave allowances.
You will work as part of a multidisciplinary team to:
Work with the PCN to support the personal care requirements for an identified cohort of patients, using available decision support aids.
Support the PCN in bringing together all of a patients identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the patient.
Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system
Support the practices in identifying appropriate patient cohorts for targeted intervention
Coordinate multidisciplinary meetings across local care organisations identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.
Provide admin support to multidisciplinary meetings including taking minutes.
Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations.
Assist patients and carers in managing their own needs, answering their queries and supporting them to address their needs.
Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding.
Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care.
Raise awareness of shared decision making and decision support tools and assist patients to be more prepared for shared decision-making conversations.
Provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN.
Work in partnership with key providers in the local community to enable improved access to services for patients
support patients to take up training and employment, and to access appropriate benefits where eligible
Explore and assist patients to access personal health budgets where appropriate
Support patients to understand their level of knowledge, skills and confidence (their activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure
Actively engage with, assist and provide advice to carers, to enable them to sustain their caring role escalating any concerns to the practice when required
Work with practices to support delivery of any national and local targets with regard to the GP contract e.g. PCN DES
Job description
Job responsibilities
The South Hams is a region of rural and coastal Devon, much of which is
designated as an Area of Outstanding Natural Beauty with some of the most
beautiful beaches and coastal walks, a great place for family and friends to
enjoy. It has a mild climate and is a wonderful place to live and work. It has
been long recognised as a 'foodies' paradise with many niche and high-end
producers servicing fantastic local restaurants, farmers markets and celebrated
food festivals.
Working for the South Hams Primary Care Network you will have the
opportunity of flexible working patterns with support and encouragement to
learn by offering training programs, mentoring and tuition assistance for
work-related courses. You will be part of a team network and where you will
feel you are making a difference. We offer an NHS pension scheme and excellent
annual leave allowances.
You will work as part of a multidisciplinary team to:
Work with the PCN to support the personal care requirements for an identified cohort of patients, using available decision support aids.
Support the PCN in bringing together all of a patients identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the patient.
Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system
Support the practices in identifying appropriate patient cohorts for targeted intervention
Coordinate multidisciplinary meetings across local care organisations identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.
Provide admin support to multidisciplinary meetings including taking minutes.
Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations.
Assist patients and carers in managing their own needs, answering their queries and supporting them to address their needs.
Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding.
Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care.
Raise awareness of shared decision making and decision support tools and assist patients to be more prepared for shared decision-making conversations.
Provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN.
Work in partnership with key providers in the local community to enable improved access to services for patients
support patients to take up training and employment, and to access appropriate benefits where eligible
Explore and assist patients to access personal health budgets where appropriate
Support patients to understand their level of knowledge, skills and confidence (their activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure
Actively engage with, assist and provide advice to carers, to enable them to sustain their caring role escalating any concerns to the practice when required
Work with practices to support delivery of any national and local targets with regard to the GP contract e.g. PCN DES
Person Specification
Knowledge and Skills
Essential
- Extensive experience of working in a Health and/or social care environment.
- Experience of implementing change.
- Experience of working directly in a community development context, adult health and social care, learning support, social housing, welfare rights, money advice and information services or public health/health improvement, including unpaid work).
- Experience of supporting people, their families and carers in a related role.
- Experience of partnership/collaborative working and of building relationships across a variety of organisations.
- Experience of data collection and providing monitoring information to assess the impact of services.
- Full UK driving license and access to a car.
- Ability to travel across the locality (5 practices) if required.
Experience
Essential
- Experience of working within a multi-disciplinary team.
- Experience of working under pressure and managing varying workloads and changing
- demands.
- Excellent communication skills with the ability to communicate orally and in written form in a confident, articulate manner.
- Ability to build relationships with others to enable and support collaborative working.
- Relevant experience of General Practice IT systems.
- Advanced keyboard skills with proven speed and accuracy
Desirable
- NHS experience
- Awareness of Data Protection legislation and appreciation of the need for discretion and confidentiality in the workplace
- Excellent organisational skills with the ability to manage the time of self, prioritising tasks to meet challenging deadlines
- High level of customer service skills
- Demonstrate honesty, integrity, care and compassion when dealing with others, utilising tact and persuasion skills when necessary
- Ability to collate and produce reports and statistical information
- Experience in minute taking
Qualifications
Essential
- GCSE Grade A* to C (9 - 4) in English and Maths, or equivalent.
- Demonstrable commitment to professional and personal development.
- Willingness to work towards further educational qualifications requirement for the role
Desirable
- NVQ Level 3 qualification or equivalent including good standard of English and maths
- Demonstrable experience in an office administrator Role in the past
Person Specification
Knowledge and Skills
Essential
- Extensive experience of working in a Health and/or social care environment.
- Experience of implementing change.
- Experience of working directly in a community development context, adult health and social care, learning support, social housing, welfare rights, money advice and information services or public health/health improvement, including unpaid work).
- Experience of supporting people, their families and carers in a related role.
- Experience of partnership/collaborative working and of building relationships across a variety of organisations.
- Experience of data collection and providing monitoring information to assess the impact of services.
- Full UK driving license and access to a car.
- Ability to travel across the locality (5 practices) if required.
Experience
Essential
- Experience of working within a multi-disciplinary team.
- Experience of working under pressure and managing varying workloads and changing
- demands.
- Excellent communication skills with the ability to communicate orally and in written form in a confident, articulate manner.
- Ability to build relationships with others to enable and support collaborative working.
- Relevant experience of General Practice IT systems.
- Advanced keyboard skills with proven speed and accuracy
Desirable
- NHS experience
- Awareness of Data Protection legislation and appreciation of the need for discretion and confidentiality in the workplace
- Excellent organisational skills with the ability to manage the time of self, prioritising tasks to meet challenging deadlines
- High level of customer service skills
- Demonstrate honesty, integrity, care and compassion when dealing with others, utilising tact and persuasion skills when necessary
- Ability to collate and produce reports and statistical information
- Experience in minute taking
Qualifications
Essential
- GCSE Grade A* to C (9 - 4) in English and Maths, or equivalent.
- Demonstrable commitment to professional and personal development.
- Willingness to work towards further educational qualifications requirement for the role
Desirable
- NVQ Level 3 qualification or equivalent including good standard of English and maths
- Demonstrable experience in an office administrator Role in the past
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.
