Job responsibilities
Ensure that people have good quality information to help them make choices about their care,
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through 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.
Explore and assist people to access personal health budgets where appropriate.
Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
Support the coordination and delivery of MDTs within PCNs.
Demonstrate flexibility and adaptability to working in a dynamic environment.
To liaise and work with multiple services and external stakeholders, acting as a conduit for information sharing and communication between the ICB, GPs, practices, KCHFT, Social Care Teams, KCC Commissioners, patients and voluntary sector.
Have a sound knowledge of health and social care policy, together with local services and health promotion initiatives, that will enable the safe transfer of clients between different provider services, and the integration of services from different providers where indicated
Support the continued development and coordination of an Integrated Health and Social Care Mutli Disciplinary team meetings approach across the Primary Care Network. This will provide a coordinated response to referrals from GPs and health and social care teams.
The PCN Community care Co-ordinators role is critical in ensuring that patients are signposted to the correct health, social or voluntary agency in a timely manner.
Communication and Relationship Skills
To provide a single point of contact for GPs and the PCN to support them with investigating service user/patient case history to improve coordination of care
To coordinate and attend Inter-professional meetings, providing appropriate feedback.
Record, minute and monitor outcomes and actions from the MDTs.
To take Health and Social Care referral information according to required process e.g. via SBAR which may involve carrying out telephone or face to face contact assessments and receiving referrals from other agencies and professionals on a daily basis. Ensuring accuracy and demonstrating non-judgmental and objective work practice and consideration of service users and carers views.
Develop and maintain effective working relationships with integrated teams including long term and practice linked teams, GP practices and other agencies to ensure that service users receive a consistent, integrated response to all contacts/referrals.
To have advanced communication skills, being able to discuss difficult and possibly contentious issues with patients, relatives and health professionals.
Knowledge, Training and Experience
The Personalised Care Institute sets out what training is available and expected for Care Coordinators this must be achieved in a timely manner.
Proven ability to work effectively in a team.
Experience of working with a variety of different stakeholders.
Ability to work with clinicians and other health care professionals.
Evidence of ongoing training and personal development.
Analytical and Judgement Skills
Demonstrate an ability to undertake duties in an autonomous manner with advice from the professional and service lead within the scope of individual competence as appropriate. To work with the PCN team others in determining the most appropriate response to individual clients in a crisis situation and in arranging and coordinating that response within the wider PCN
To analyse the information provided and determine which service best meets the need of the patient.
Planning and Organisational Skills
To be able to plan, organise and prioritise a busy caseload with conflicting demands on time.
To be able to organise and coordinate MDT and other meetings as required.
To take an active role in identifying service development initiatives.
Determine the patients holistic support needs accurately over the telephone or face-to-face.
Signpost patients to relevant support for important financial matters i.e. personal budgets and benefits or refer to SPLWs.
Implement and follow up key action points from the MDT meetings on the agreed care plan or personalised care and support plans (PCSP).
Effectively communicate a patients needs within a multidisciplinary team meeting environment
Physical Skills
Ability to drive across the locality. Mainly short journeys.
Ability to transport and install small items of equipment
The ability to use a range of a keyboard, IT packages and applications
Responsibility for Patient/Client Care
To develop an understanding and awareness of all the resources available, both public and independent to meet the needs of people in the community.
Identify and process any safeguarding and quality of care issues and refer onwards to ensure that clients welfare is protected as per agreed protocols.
To coordinate a short term caseload and to act as a Key Worker on an interim basis, predominantly in the early stages of health and social care interventions.
To work as a Trusted Assessor to provide small items of equipment and minor adaptations to patients following an assessment of their need, including baseline observations.
Responsible for Policy and Service Development Implementation
Apply Service and organisational policies and procedures as defined to ensure consistency, fairness, transparency and quality of service.
To support the development of the MDT process across the PCN. Support the development of the PCN Multidisciplinary Care Planning meetings as required
Alert members of the PCN for support/guidance if concerned about a patients mental or physical health
Demonstrate knowledge and understanding of relevant mental health legislation e.g. Mental Capacity Act.
Responsibilities for Financial and Physical Resources
Triage and refer patients for appropriate care / equipment package to meet their needs which have been identified through an MDT/PCN approach
Responsibilities for Human Resources (HR)
To participate in the induction and training of new members of staff and to contribute to the multi-disciplinary team development. To provide cover for colleagues as and when required.
Responsibilities for Information Resources
To use EMIS as the main reporting system for the PCN patients.
To use KMCR and any other systems and health databases to search and view service user / patient information. To input data as necessary relating to referral, assessment and outcomes when appropriate, ensure all clients recorded information is accurate, up to date and factual.
To understand and follow procedures and policies on information governance, with strict adherence to protocols regarding the sharing of personal and confidential information between different organisations and individuals.
Freedom to Act
The post holder will have a named GP for clinical supervision and a line manager for general day to day management.
Physical Effort
Infrequent lifting and transporting light weight equipment.
Long periods of sitting, PC use.
Mental Effort
Long periods of concentration when processing referrals and visiting patients.
Unpredictable work pattern with frequent interruptions which may mean re-prioritising tasks.
Emotional Effort
Occasional direct exposure to potentially emotionally demanding situations e.g. dealing with difficult patients / carers, organising referrals for the terminally ill.
Working Conditions
Occasional exposure to unpleasant home environments e.g. extreme smells
Lone working in the community
Frequent VDU use