Care Coordinator

Job description

Job responsibilities

The post holder will undertake work in line with BRHC directed priorities. (Full job description available on request)

Proactively identifying and working with a cohort of people to support their personalised care requirements. This could include:

• the development of digital solutions across the health centre supporting access needs of patients;
• care navigation of patients via our online consultation platform, Ask My GP
• supporting the nurse administrator of personalised annual recall invites for patients with long term conditions;
• Engaging with and developing processes in support of localised, agreed, access processes.
• Facilitating enhanced processes to support the care coordination of patients with complex need.
• Where possible, utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care;
• Where possible, support patients to utilise decision aids in preparation for a shared decision-making conversation;
• Where possible; 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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health;
• Support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers;
• Additionally;
• Resolving any queries in relation to these workstreams and ensuring all parties are kept informed of progress towards resolution.
• Supporting Quality and Outcome Frameworks and other DES specifications.
• 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
• Providing coordination and navigation for patients/carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles.
• Supporting residents in care homes/LD homes ensuring personalised care is delivered through collaborative working between health, social care, voluntary, community and social enterprise sector and care home partners.
• At times you will be required to support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them, and educating them to promote and support their independence.
• Be proactive in developing strong link with local agencies, and in encouraging equality and inclusions.
• Any other duties relevant to this role.
• Partnership working and communication
• Works closely and in partnership with the Social Prescribing Link Worker(s) or social prescribing service provider and Health and Wellbeing Coach(es), in order to deliver the key responsibilities;
• Develop strong working relationships with GPs, practice teams and other health care col-leagues to optimise the timely and good quality delivery of services to patients and to support the working lives of colleagues.
• Work collaboratively with neighbourhood colleagues to share best practises.
• Ensure that all relevant professionals are kept up-to-date so that any issues or concerns can be appropriately addressed and supported.
• Keep accurate, up-to-date, contemporaneous and appropriately Snomed coded consultation records of patient contacts, appropriately using EMIS software and other record, referral and messaging systems relevant to the role, adhering to information governance and data protection legislation.
• Maintain records of interventions to enable monitoring and evaluation of the service.
• Provide regular feedback to relevant stakeholders about service progress.
• Additionally:
• Support a PCN in the assurance needs to:
• a. Ensure that basic safeguarding processes in place for vulnerable individuals; and
• b. Ensure that opportunities for the patient to develop friendships and a sense of belonging, as well as to build knowledge, skills and confidence.
• General Administration
• To have a thorough knowledge of all Practice procedures
• To work in accordance with written protocols
• Generate patient prescriptions manually and electronically
• Photocopy, scan and e-mail documents as requested by colleagues or required by practice procedure
• Process, file and allocate electronic consultation requests.
• Process queries from the local care home and arrange clinical intervention where required.
• Process changes in patient contact details in line with practice policy
• Complete any other administrative tasks as requested by the Reception Lead or the partners

Person Specification

Experience

Essential

• Experience of working within General Practice

Desirable

• Experience of Emis clinical system
• Experience of online consultation platform Ask My GP

Skills and General

Essential

• Good organisational skills
• Be able to work under pressure
• Be flexible in covering for annual leave

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

Bodmin Road Health Centre

Address

Bodmin Road Health Centre

Bodmin Road

Sale

Cheshire

M33 5JH

Employer's website

https://www.bodminroadhealthcentre.co.uk/ (Opens in a new tab)