Job summary
As a Frailty Care Coordinator you will work as a key part of the primary
care multidisciplinary team. You will be the key link to the people whose care
you are supporting, operating as a go to person to ensure that their care is
seamless, they are active decision makers in their own care, and that everyone
involved is working together. Our Frailty Care Coordinators will provide extra
time, capacity and expertise to support patients in preparing for or in
following up clinical conversations they have with primary care professionals.
You will work closely with the GPs and other primary care professionals within
the practice to identify and manage a caseload of identified patients, making
sure that appropriate support is made available to them and their carers, and
ensuring that their changing needs are addressed. Using agreed templates and
assessment tools you will ensure an outcome-based care plan is co-produced with
each person. You will review plans at regular intervals to capture progress,
ensure they remain appropriate for the individual and identify any input
required from wider team members including healthcare specialists.
Main duties of the job
Take overall responsibility for coordination and delivery of the MDT
meetings.
There is a requirement for at least 2 sessions per week, one of which will be led by a GP, whereas the successful applicant would be expected to manage the second session.
The successful candidate will schedule the MDT meetings,
manage the meeting agenda items; ensuring that all new referrals are
identified, and information circulated to team members in advance of the
meeting. Utilise population health intelligence and PCN / Partner data to
proactively identify and work with a cohort of patients to deliver personalised
care.
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.
About us
Primary Care Teams are growing and evolving and now seeking more staff
to deliver the care services to our patients. You would lead a Multi-Disciplinary Team (MDT) within Kettering and South West Rural Primary Care Network (K&SWR PCN) comprising of colleagues from general practice, Adult Social Care and Age UK to support GPs and
clinical teams at enhancing patient services in the local community.
Vibrant, friendly working atmosphere with great opportunities.
Job description
Job responsibilities
Take overall responsibility for coordination and delivery of the MDT
meetings.
A key role of the Care Coordinator will be to schedule the MDT meetings,
manage the meeting agenda items; ensuring that all new referrals are
identified, and information circulated to team members in advance of the
meeting. Utilise population health intelligence and PCN / Partner data to
proactively identify and work with a cohort of patients to deliver personalised
care.
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 when engaging with their health and wellbeing.
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.
Provide coordination and navigation for people and their carers across
health and care services, working closely with social prescribing link workers,
health and wellbeing coaches, and other primary care professionals.
Work with the GPs and other primary care professionals within the practice
to identify and manage a caseload of patients, and where required and as
appropriate, refer people back to other health professionals.
Raise awareness of how to identify patients who may benefit from shared
decision making and support staff and patients to be more prepared to have
shared decision-making conversations.
Job description
Job responsibilities
Take overall responsibility for coordination and delivery of the MDT
meetings.
A key role of the Care Coordinator will be to schedule the MDT meetings,
manage the meeting agenda items; ensuring that all new referrals are
identified, and information circulated to team members in advance of the
meeting. Utilise population health intelligence and PCN / Partner data to
proactively identify and work with a cohort of patients to deliver personalised
care.
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 when engaging with their health and wellbeing.
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.
Provide coordination and navigation for people and their carers across
health and care services, working closely with social prescribing link workers,
health and wellbeing coaches, and other primary care professionals.
Work with the GPs and other primary care professionals within the practice
to identify and manage a caseload of patients, and where required and as
appropriate, refer people back to other health professionals.
Raise awareness of how to identify patients who may benefit from shared
decision making and support staff and patients to be more prepared to have
shared decision-making conversations.
Person Specification
Qualifications
Essential
- Professional clinical qualifications or competencies commensurate to a Band 7 AfC appointment.
- GCSE or equivalent grade C level qualification in Maths and English.
- Experience Minimum of one years' experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
- Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
- Experience providing advice/signposting to patients.
- Experience of undertaking quality improvement activity.
- Excellent organisational and administration skills.
- Ability to analyse and interpret information and present results in a clear and concise manner.
- Able to prioritise and manage own workload.
Desirable
- Experience of working in a multi-disciplinary setting where influence and negotiation is required.
- Experience of using technology and digital tools to support health and wellbeing.
- Experience of co-production with patients or service-users.
- Skills and Knowledge Excellent influencing and negotiating skills.
Experience
Essential
- Experience working within a healthcare setting and interacting with patients.
- Ability to manage own outputs and wider MDT's workload.
- Recognition of priorities and sound time/resource management
- Excellent influencing and negotiating skills.
Person Specification
Qualifications
Essential
- Professional clinical qualifications or competencies commensurate to a Band 7 AfC appointment.
- GCSE or equivalent grade C level qualification in Maths and English.
- Experience Minimum of one years' experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
- Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
- Experience providing advice/signposting to patients.
- Experience of undertaking quality improvement activity.
- Excellent organisational and administration skills.
- Ability to analyse and interpret information and present results in a clear and concise manner.
- Able to prioritise and manage own workload.
Desirable
- Experience of working in a multi-disciplinary setting where influence and negotiation is required.
- Experience of using technology and digital tools to support health and wellbeing.
- Experience of co-production with patients or service-users.
- Skills and Knowledge Excellent influencing and negotiating skills.
Experience
Essential
- Experience working within a healthcare setting and interacting with patients.
- Ability to manage own outputs and wider MDT's workload.
- Recognition of priorities and sound time/resource management
- Excellent influencing and negotiating 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.