Care Coordinator

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.

Multi-Disciplinary Teams

Overall responsibility for arranging the daily PCN led MDT meetings and the smooth running of integrated care within the team setting. A key role of the Care Coordinator is to ensure that all new referrals are identified, and information circulated to team members in advance of the meeting.

Take notes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.

Patient Identification: Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.

Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.

Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the daily MDT meetings.

Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT.

Signpost team members, service users and carers to relevant services

Direct patient facing work.

Manage a caseload of patients identified through the MDT or practice.

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 take up training and employment, and to access appropriate benefits where eligible.

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.

Refer or liaise with the Health Coaches and Village Agents as appropriate.

Communication and collaborative working relationships

Demonstrates ability to work as a member of a team.

Can recognise personal limitations and refer to more appropriate colleague(s) when necessary.

Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.

Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations.

Work with service users, PCN practices and partners e.g., Care Homes to ensure new referrals are logged and allocated.

Develop excellent working relationships with all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT.

Acting as a point of contact for residents, families, carers and professionals who visit the care home, such as MDT members and in-reach specialists.

Meet regularly with the clinical lead and review case load and MDT function.

Keep the MDT and OHP organisation abreast of good news stories.

Provide background information about individuals for the daily MDT meetings.

Communicate effectively with service users and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals.

Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT

Other responsibilities

To always act in an anti-discriminatory manner

To be able to plan and respond to workload according to operational priorities.

To support the delivery of these functions across wider locality areas where necessary

To undertake any training required to maintain competency including mandatory training.

To contribute to, and work within a safe working environment.

The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures.

The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.

The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.

Patient Care

Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding.

Effectively use all methods of communication and be aware of and manage barriers to communication.

Effectively recognise and manage challenging behaviors, carers and or relatives

Provide information to patients, their carers and/or relatives on behalf of the team.

The PCN will ensure the PCNs Care Coordinator can discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g., abuse, domestic violence and support with mental health) with a relevant GP.

Supporting Care Delivery

Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated.

Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.

Follow through with service users and others involved to ensure all services and care arrangements are in place.

Autonomy/Scope within Role

The post holder will be required to work within clearly defined organisational protocols, policies and procedures.

Key Relationships

Key Working Relationships Internal:

Clinical Lead for the MDT

GPs and General practice teams within the PCN

PCN Care Coordinator Team Leader

MDT members including but not exhaustive: Clinical Pharmacists, technicians, District Nurses, LARCH Team, OPMH, IRT, Adult Social Care, Paramedics, Social Prescribing Link Workers, Village Agents

Key Working Relationships External:

GPs from neighbouring PCNs

Service providers

Social care

Voluntary services

Patients/service users

Carers/relatives

Person Specification

Other

Essential

• Access to and ability to use transport as travel between sites across the county will be required for work, meetings and training.
• Professional attitude and assertive approach
• Committed to development.
• Conscientious, hardworking and self- motivated to work with minimal supervision.
• Creative and tenacious in finding solutions to difficult problems.
• Ability to work with information, clinicians, social workers and managers.
• Ability to meet deadlines and work under pressure.
• Ability to engage and sustain relationships with all professionals, other organisations and service-users.
• Approachable and flexible
• Honest and reliable
• Enthusiastic
• Sensitive to patients needs.
• Willingness to undergo further training or development.

Qualifications

Essential

• Educated to GCSE level or equivalent

Desirable

• Diploma/ HNC level (or relevant experience
• ECDL or equivalent
• NVQ Level 3 Business Administration (or relevant experience

Experience

Essential

• 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
• Proven record of excellent written and verbal communication skills and interpersonal skills
• Evidence of excellent knowledge of Microsoft Office
• 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
• Strong analytical and judgement skills
• Ability to analyse and interpret information and present results in a clear and concise manner.
• Excellent organisational and administration skills
• Experience providing advice/signposting to users.

Desirable

• Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (desirable)
• Knowledge/familiarity with medical terminology
• Understanding of current issues facing the NHS
• Understanding of health and social care processes
• Able to use NHS Choices website effectively

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