Job summary
We have an exciting and innovative
new opportunity for a Care Co-ordinator working on the Proactive Care project
for Bridgwater Bay Primary Care Network. The role involves working with a team
of clinicians to enable people to live healthy independent lives and support
active self-management and prevention. The candidate will possess excellent
communication and organisation skills and have experience in a Health, Social
Care or Educational background workplace.
Candidates should have excellent IT skills and have an interest in
collecting data from clinical systems to help develop the service and support
the PCN Management Team.
The successful candidate will join
our growing PCN workforce and support the delivery of care bringing together
all the information about a patient's identified care and support needs and
exploring options to meet these by identifying and signposting to appropriate
clinicians. Patient needs will be discussed at MDT meetings with clear plans
put into place to support people in our community.
Care coordinators play an important
role within a PCN to proactively identify and work with people to provide
coordination and navigation of care and support across health and care
services.
They work closely with GPs and
practice teams to support patients in the community, acting as a central point
of contact to ensure appropriate support is made available to them; supporting
them to understand and manage their condition and ensuring their changing needs
are addressed.
Main duties of the job
- Working
with clinicians to provide support in neighbourhood areas with an emphasis on self-management
and prevention of avoidable illness.
- Provide
coordination and navigation for health and care services, working closely with
social prescribing link workers, health and wellbeing coaches, and other
primary care professionals; helping to ensure patients receive a joined-up
service and the most appropriate support.
- Support
the coordination and delivery of multidisciplinary teams with the PCN.
- Raise
awareness of how to identify patients who may benefit from shared decision
making and support PCN staff and patients to be more prepared to have shared
decision making conversations.
- Support
PCNs in developing communication channels between GPs and other agencies.
- Maintain
records of referrals and interventions to enable monitoring and evaluation of
the service.
- Support
practices to keep care records up-to-date by identifying and updating missing
or out-of-date information about the patient's circumstances.
- Enable
access to personalised care and support.
- Take
referrals for individuals or proactively identify patients who could benefit
from support through care coordination.
- Ensure
personalised care and support plans are communicated to the GP and any other
professionals involved in the patient's care and uploaded to the relevant
online care records, with activity recorded using the relevant SNOMED codes.
About us
Bridgwater Primary Care Network (PCN) is the largest PCN in Somerset
with 9 GP practices, a health & wellbeing hub and a diverse population
spread across town and rural locations.
As a PCN we are forward
thinking, innovate and driven to deliver the best patient care for our population.
This includes health population management, and this role ties in with
supporting that and tracking the improvements we can make to patients lives.
In January 2023 we started an
exciting joint venture with Somerset NHS Foundation Trust to open a Health and Wellbeing
Hub at the old Victoria Park Medical Centre. This is a flagship hub, the first
of its kind that will bring together Primary and Secondary care all under one
roof to support the Bridgwater Bay community.
The focus of the hub is
preventative care and supporting self-care management to the population.
Job description
Job responsibilities
Key roles
and responsibilities
- Working
with clinicians to provide support in neighbourhood areas with an emphasis on self-management
and prevention of avoidable illness.
- Provide
coordination and navigation for health and care services, working closely with
social prescribing link workers, health and wellbeing coaches, and other
primary care professionals; helping to ensure patients receive a joined-up
service and the most appropriate support.
- Work
collaboratively with GPs and other primary care professionals within the PCN to
proactively identify and manage a caseload, and where appropriate, refer back
to other health professionals within the PCN.
- Support
the coordination and delivery of multidisciplinary teams with the PCN.
- Raise
awareness of how to identify patients who may benefit from shared decision
making and support PCN staff and patients to be more prepared to have shared
decision making conversations.
- Carry
out holistic assessments to identify patients in the community that could
benefit from healthcare intervention. Aid patients in managing any long term
conditions they may have, supporting self management and access to care.
- Support
PCNs in developing communication channels between GPs and other agencies.
- Maintain
records of referrals and interventions to enable monitoring and evaluation of
the service.
- Support
practices to keep care records up-to-date by identifying and updating missing
or out-of-date information about the patient's circumstances.
- Contribute
to risk and impact assessments, monitoring and evaluations of the service.
- Work
with commissioners, integrated locality teams and other agencies to support and
further develop the role.
- Enable
access to personalised care and support.
- Take
referrals for individuals or proactively identify patients who could benefit
from support through care coordination.
- Have
a positive, empathetic and responsive conversation with the patient about their
needs and when appropriate review personalised care and support plans.
- Ensure
personalised care and support plans are communicated to the GP and any other
professionals involved in the patient's care and uploaded to the relevant
online care records, with activity recorded using the relevant SNOMED codes.
- Help
to transition seamlessly between services and support them to navigate through
the health and care system.
- Refer
onwards to appropriate health care professionals such as, social prescribing
link workers, voluntary sector workers and health and wellbeing coaches where
required.
- Regularly
liaise with the range of multidisciplinary professionals and colleagues
involved in the patient's care, facilitating a coordinated approach and
ensuring everyone is kept up to date so that any issues or concerns can be
appropriately addressed and supported.
- Actively
participate in multidisciplinary team meetings in the PCN and individual
practices as and when appropriate.
- Identify
when action or additional support is needed, alerting a named clinical contact
in addition to relevant professionals, and highlighting any safety concerns.
- Keep
accurate and up-to-date records of contacts, appropriately using GP and other
records systems relevant to the role, adhering to information governance and
data protection legislation.
- Work
sensitively with patients to capture key information, while tracking of the
impact of care coordination on their health and wellbeing.
- Encourage
patients to provide feedback and to share their stories about the impact of
care coordination on their lives.
- Record
and collate information according to agreed protocols and contribute to
evaluation reports required for the monitoring and quality improvement of the
service.
Professional development- Work
with a named clinical point of contact for advice and support.
- Undertake
continual personal and professional development, taking an active part in
reviewing and developing the role and responsibilities, and provide evidence of
learning activity as required.
- Adhere
to organisational policies and procedures, including confidentiality,
safeguarding, lone working, information governance, equality, diversity and
inclusion training and health and safety.
Miscellaneous- Establish
strong working relationships with GPs and practice teams and work
collaboratively with other care coordinators, social prescribing link workers
and health and wellbeing coaches, supporting each other, respecting each
others views and meeting regularly as a team.
- Act
as a champion for personalised care and shared decision making within the PCN.
- Demonstrate
a flexible attitude and be prepared to carry out other duties as may be
reasonably required from time to time within the general character of the post
or the level of responsibility of the role, ensuring that work is delivered in
a timely and effective manner.
- Identify
opportunities and gaps in the service and provide feedback to continually
improve the service and contribute to business planning.
- Contribute
to the development of policies and plans relating to equality, diversity and
reduction of health inequalities.
- Work
in accordance with the practices and PCNs policies and procedures
- Duties
may vary from time to time without changing the general character of the post
or the level of responsibility.
- Contribute
to the wider aims and objectives of the PCN to improve and support primary
care.
- To
support in the delivery of the PCN Network DES, enhanced services and other
service requirements on behalf of the PCN.
Job description
Job responsibilities
Key roles
and responsibilities
- Working
with clinicians to provide support in neighbourhood areas with an emphasis on self-management
and prevention of avoidable illness.
- Provide
coordination and navigation for health and care services, working closely with
social prescribing link workers, health and wellbeing coaches, and other
primary care professionals; helping to ensure patients receive a joined-up
service and the most appropriate support.
- Work
collaboratively with GPs and other primary care professionals within the PCN to
proactively identify and manage a caseload, and where appropriate, refer back
to other health professionals within the PCN.
- Support
the coordination and delivery of multidisciplinary teams with the PCN.
- Raise
awareness of how to identify patients who may benefit from shared decision
making and support PCN staff and patients to be more prepared to have shared
decision making conversations.
- Carry
out holistic assessments to identify patients in the community that could
benefit from healthcare intervention. Aid patients in managing any long term
conditions they may have, supporting self management and access to care.
- Support
PCNs in developing communication channels between GPs and other agencies.
- Maintain
records of referrals and interventions to enable monitoring and evaluation of
the service.
- Support
practices to keep care records up-to-date by identifying and updating missing
or out-of-date information about the patient's circumstances.
- Contribute
to risk and impact assessments, monitoring and evaluations of the service.
- Work
with commissioners, integrated locality teams and other agencies to support and
further develop the role.
- Enable
access to personalised care and support.
- Take
referrals for individuals or proactively identify patients who could benefit
from support through care coordination.
- Have
a positive, empathetic and responsive conversation with the patient about their
needs and when appropriate review personalised care and support plans.
- Ensure
personalised care and support plans are communicated to the GP and any other
professionals involved in the patient's care and uploaded to the relevant
online care records, with activity recorded using the relevant SNOMED codes.
- Help
to transition seamlessly between services and support them to navigate through
the health and care system.
- Refer
onwards to appropriate health care professionals such as, social prescribing
link workers, voluntary sector workers and health and wellbeing coaches where
required.
- Regularly
liaise with the range of multidisciplinary professionals and colleagues
involved in the patient's care, facilitating a coordinated approach and
ensuring everyone is kept up to date so that any issues or concerns can be
appropriately addressed and supported.
- Actively
participate in multidisciplinary team meetings in the PCN and individual
practices as and when appropriate.
- Identify
when action or additional support is needed, alerting a named clinical contact
in addition to relevant professionals, and highlighting any safety concerns.
- Keep
accurate and up-to-date records of contacts, appropriately using GP and other
records systems relevant to the role, adhering to information governance and
data protection legislation.
- Work
sensitively with patients to capture key information, while tracking of the
impact of care coordination on their health and wellbeing.
- Encourage
patients to provide feedback and to share their stories about the impact of
care coordination on their lives.
- Record
and collate information according to agreed protocols and contribute to
evaluation reports required for the monitoring and quality improvement of the
service.
Professional development- Work
with a named clinical point of contact for advice and support.
- Undertake
continual personal and professional development, taking an active part in
reviewing and developing the role and responsibilities, and provide evidence of
learning activity as required.
- Adhere
to organisational policies and procedures, including confidentiality,
safeguarding, lone working, information governance, equality, diversity and
inclusion training and health and safety.
Miscellaneous- Establish
strong working relationships with GPs and practice teams and work
collaboratively with other care coordinators, social prescribing link workers
and health and wellbeing coaches, supporting each other, respecting each
others views and meeting regularly as a team.
- Act
as a champion for personalised care and shared decision making within the PCN.
- Demonstrate
a flexible attitude and be prepared to carry out other duties as may be
reasonably required from time to time within the general character of the post
or the level of responsibility of the role, ensuring that work is delivered in
a timely and effective manner.
- Identify
opportunities and gaps in the service and provide feedback to continually
improve the service and contribute to business planning.
- Contribute
to the development of policies and plans relating to equality, diversity and
reduction of health inequalities.
- Work
in accordance with the practices and PCNs policies and procedures
- Duties
may vary from time to time without changing the general character of the post
or the level of responsibility.
- Contribute
to the wider aims and objectives of the PCN to improve and support primary
care.
- To
support in the delivery of the PCN Network DES, enhanced services and other
service requirements on behalf of the PCN.
Person Specification
Qualifications
Essential
- High level of written and verbal communication skills
- -5 GCSEs including English and Mathematics
- Demonstratable commitment to professional and personal development.
- Ability to use Microsoft Office applications for example: Word, Excel, Powerpoint and Outlook is essential.
- Excellent IT skills
Experience
Essential
- KNOWLEDGE
- Knowledge and understanding of administrative elements surrounding personalised and support care planning.
- Understanding of, and commitment to, equality, diversity and inclusion.
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Knowledge of how the NHS works, including primary care and PCNs.
- Ability to recognise and work within limits of competence and seek advice when needed.
- Basic knowledge of long term conditions and the complexities involved - medical, physical, emotional and social.
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
- EXPERIENCE
- Experience of administrative and IT systems.
- Experience of working within multi- professional team environments.
- Experience of supporting people, their families and carers in a related role.
- Experience of data collection and using tools to measure the impact of service.
Communication and Other
Essential
- COMMUNICATION SKILLS
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
- OTHER
- Access to own transport.
- Ability to travel across the locality.
Person Specification
Qualifications
Essential
- High level of written and verbal communication skills
- -5 GCSEs including English and Mathematics
- Demonstratable commitment to professional and personal development.
- Ability to use Microsoft Office applications for example: Word, Excel, Powerpoint and Outlook is essential.
- Excellent IT skills
Experience
Essential
- KNOWLEDGE
- Knowledge and understanding of administrative elements surrounding personalised and support care planning.
- Understanding of, and commitment to, equality, diversity and inclusion.
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Knowledge of how the NHS works, including primary care and PCNs.
- Ability to recognise and work within limits of competence and seek advice when needed.
- Basic knowledge of long term conditions and the complexities involved - medical, physical, emotional and social.
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
- EXPERIENCE
- Experience of administrative and IT systems.
- Experience of working within multi- professional team environments.
- Experience of supporting people, their families and carers in a related role.
- Experience of data collection and using tools to measure the impact of service.
Communication and Other
Essential
- COMMUNICATION SKILLS
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
- OTHER
- Access to own transport.
- Ability to travel across the locality.
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.
