Job summary
We are introducing practice based Care Coordinators into our PCN practices as part of the wider PCN personalised care team. This is an exciting time to join North Sedgemoor PCN as we introduce and develop new roles into Primary Care to help practice sustainability.
This is a new role for practices and successful applicants will be an integral part of the practice team.
This role is suitable for those with NHS, Primary Care or Social Care experience who wish to expand and develop their roles; it is also suitable for people new to the NHS and Primary Care who have worked in a people facing environment and who want a rewarding and busy role that helps provide extra capacity in primary care to support patients.
Applicants, using their personal attributes and previous work experiences must be capable of working autonomously and accountably for the benefit of the patients and the practices
The role of a care coordinator is to improve continuity of care by supporting patients and to help people to manage
their needs through answering queries, making and managing appointments, and
ensuring that people have good quality written or verbal information to help
them make choices about their care, using tools to understand peoples level of
knowledge, confidence in skills in managing their own health.
Candidates will need to be able to demonstrate ability to work as a member of a team,
build effective working relationships, manage and prioritise their workload.
Main duties of the job
Patient
Identification:
- Receive and collate
information from transfers of care (i.e. hospital admissions and
discharges) plus out of hours calls and present this information.
- Liaise with service providers
and clinicians to identify frequent flyers, and new service users utilising
risk stratification tools and present this information to the daily MDT
meetings.
- Support the completion of
new referrals
- Signpost team members,
service users and carers to services
Direct
patient facing work- Support patients to utilise
decision aids in preparation for a shared decision-making conversation.
- Holistically bring together
all of a persons 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 person.
- Help people to manage their
needs through answering queries, making and managing appointments, and ensuring
that people have good quality written or verbal 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 through the use of the
Patient Activation Measure.
- Assist people to access
self-management education courses, peer support or interventions that support
them in their health and wellbeing and increase their activation level.
- Explore and assist people to
access personal health budgets where appropriate.
About us
PCNs (Primary Care Network) are groups of GP practices working more closely together, with other primary and community care staff and health and care organisations, providing integrated services
North Sedgemoor PCN covers 5 GP practices in North Sedgemoor, supporting approximately 47, 000 patients.
North Sedgemoor PCN is a forward thinking group of practices who believe in developing people who work with them in order to give the best possible care to the people of North Sedgemoor.The PCN in the process of developing
new models of care.
Care Coordinators are part of the Somerset Social Prescribing Model. The successful candidates will work alongside social prescribing link workers and Health Coaches to provide an all-encompassing approach to personalised care and enable people to work out how best to use the health and care system.
Based in one of the surgeries as part of their team and at the PCN Hub in Berrow working with the other mmebers of the personalise care team this is a unique opportunity to join a developing area of healthcare.
Job description
Job responsibilities
The post holder
will contribute to tackling inequalities in health and social care particularly
regarding individuals with long-term conditions. An ethos of promotion of
independence and partnership-working is integral to this post.
Care
coordinators provide extra time, capacity, and expertise to support patients in
preparing for clinical conversations or in following up discussions with
primary care professionals.
They 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.
The role will ensure
patient health and care planning is timely, efficient, and patient-centred. 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.
They will work closely
with other parts of the practice team, e.g., reception/admin.
Working closely
with the GPs and other primary care colleagues within the primary care network
(PCN) to identify and manage a caseload of identified patients, making sure
that appropriate support is made available to them and their carers (if
appropriate), and ensuring that their changing needs are addressed. They focus
on the delivery of personalised care to reflect local PCN priorities, health
inequalities or at-risk groups of patients.
This role will involve working within one of the 5
practices in the North Sedgemoor area. Care
Coordinators may be based in any one of the surgery's
As part of this role you will be required to contribute to the PCN Enhanced Access requirement via a team shared rota. Enhanced access is 6.30-8.00pm (weekdays) and 9.00-5.00pm (Saturday)
Job description
Job responsibilities
The post holder
will contribute to tackling inequalities in health and social care particularly
regarding individuals with long-term conditions. An ethos of promotion of
independence and partnership-working is integral to this post.
Care
coordinators provide extra time, capacity, and expertise to support patients in
preparing for clinical conversations or in following up discussions with
primary care professionals.
They 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.
The role will ensure
patient health and care planning is timely, efficient, and patient-centred. 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.
They will work closely
with other parts of the practice team, e.g., reception/admin.
Working closely
with the GPs and other primary care colleagues within the primary care network
(PCN) to identify and manage a caseload of identified patients, making sure
that appropriate support is made available to them and their carers (if
appropriate), and ensuring that their changing needs are addressed. They focus
on the delivery of personalised care to reflect local PCN priorities, health
inequalities or at-risk groups of patients.
This role will involve working within one of the 5
practices in the North Sedgemoor area. Care
Coordinators may be based in any one of the surgery's
As part of this role you will be required to contribute to the PCN Enhanced Access requirement via a team shared rota. Enhanced access is 6.30-8.00pm (weekdays) and 9.00-5.00pm (Saturday)
Person Specification
Skills and Attributes
Essential
- Proven record of excellent written and verbal communication skills and interpersonal skills
- Able to deal with service users sensitively
- Able to work as part of a team
- Able to prioritise and manage own workload
- Excellent motivational and influencing skills
- Excellent negotiating skills
- Car user (to travel between more than one GP practice)
- Excellent interpersonal skills Strong
Experience
Essential
- Experience and Knowledge Required:
- Experience of working with the public
- Evidence of excellent knowledge of Microsoft Office
- Experience in use of databases
- Experience of administrative duties
- Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality
- Working in a multi-disciplinary setting where influence and negotiation is required
- Working in a busy and demanding environment whilst delivering in a timely manner
- Understanding of current issues facing the NHS
Desirable
- Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
- Knowledge/familiarity with medical terminology
- Understanding of health and social care processes
Qualifications
Essential
- GCSEs/Diploma/ HNC level (or relevant experience) ECDL or equivalent NVQ Level 3 Business Administration (or relevant experience)
- Ongoing internal and external training to keep up to date with changes/ developments
Person Specification
Skills and Attributes
Essential
- Proven record of excellent written and verbal communication skills and interpersonal skills
- Able to deal with service users sensitively
- Able to work as part of a team
- Able to prioritise and manage own workload
- Excellent motivational and influencing skills
- Excellent negotiating skills
- Car user (to travel between more than one GP practice)
- Excellent interpersonal skills Strong
Experience
Essential
- Experience and Knowledge Required:
- Experience of working with the public
- Evidence of excellent knowledge of Microsoft Office
- Experience in use of databases
- Experience of administrative duties
- Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality
- Working in a multi-disciplinary setting where influence and negotiation is required
- Working in a busy and demanding environment whilst delivering in a timely manner
- Understanding of current issues facing the NHS
Desirable
- Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
- Knowledge/familiarity with medical terminology
- Understanding of health and social care processes
Qualifications
Essential
- GCSEs/Diploma/ HNC level (or relevant experience) ECDL or equivalent NVQ Level 3 Business Administration (or relevant experience)
- Ongoing internal and external training to keep up to date with changes/ developments
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
North Sedgemoor PCN
Address
Axbridge & Wedmore Medical Practice
The Surgery, Houlgate Way,
Axbridge,
Somerset
BS26 2BJ