Job summary
Morley and District Primary Care Network have an exciting opportunity for an experienced care co-ordinator to join their team.
This is a important role that will help shape and form the layout of our local healthcare offer in Morley, Leeds.
The suitable candidate should be passionate about making a difference in primary care and enjoy working as part of a multi-disciplinary team across services.
Care co-ordinators 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 co-ordination and navigation of
care and support across health and care services.
They work closely with GPs and practice teams to manage a
caseload of patients, acting as a central point of contact to ensure
appropriate support is made available to people and their carers; supporting
them to understand and manage their condition and ensuring their changing needs
are addressed.
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.
Care co-ordinators could provide time, capacity and
expertise to support people in preparing for, or following-up, clinical
conversations. Enabling them to be more actively involved in managing their
care and supporting them to make choices that are right for them.
Main duties of the job
We are looking for a care coordinator to work on our population health management needs, this may involve been in the community talking to patients and managing their care.
Key
responsibilities
Work with people,
their families and carers, to improve their understanding of their condition.
Support people to develop and
review personalised care and support plans to manage their needs and achieve
better healthcare outcomes.
Work with people,
their families, carers and healthcare team members to encourage effective
help-seeking behaviours.
Support PCNs in
developing communication channels between GPs, people and their families and
carers and other agencies.
Help people to
manage their needs by providing a contact to answer queries, make and manage
appointments, and ensure that people have good quality written or verbal
information to help them make choices about their care.
Provide co-ordination
and navigation for people and their carers across health and care services. Helping
to ensure patients receive a joined-up service and the appropriate support from
the right person at the right time.
Work
collaboratively with GPs and other primary care professionals within the PCN to
proactively identify and manage a caseload, which may include patients with
long-term health conditions, and where appropriate, refer back to other health
professionals within the PCN.
About us
We are a 6 practice PCN with approximately 65,000 patients. We are rapidly developing our multi-disciplinary workforce, embedding our roles, developing our team that makes a real difference to our patients and our practices. we pride ourselves on tackling the needs of our patients by working together to provide personalised health support for our population health needs.
Morley is a thriving area of South Leeds with a strong community. The area is a highly sought after place to live due to its excellent links to the city and busy town centre.
We would Welcome applicants who have a strong admin and people background.
Job description
Job responsibilities
Enable access to personalised care and support
Take referrals or proactively identify people who
could benefit from support through care co-ordination.
Have a positive, empathetic and responsive
conversations with people and their families and carer(s), about their needs.
Increasing patients understanding of how to manage
and improve health and wellbeing by offering advice and guidance.
Develop an in-depth knowledge of the local health
and care infrastructure and know how and when to enable people to access
support and services that are right for them.
Use tools to measure peoples levels of knowledge,
skills and confidence in managing their health and tailor support to them
accordingly.
Support people to develop and implement
personalised care and support plans.
Review and update personalised care and support
plans at regular intervals.
Ensure personalised care and support plans are
communicated to the GP and any other professionals involved in the persons
care and uploaded to the relevant online care records, with activity recorded
using the relevant SNOMED codes.
Co-ordinate and integrate careMake and manage appointments for patients, related
to primary, secondary, community, local authority, statutory, and voluntary
organisations.
Help people transition seamlessly between secondary
and community care services, conducting follow-up appointments, and supporting
people to navigate through the wider health and care system.
Refer onwards to social prescribing link workers
and health and wellbeing coaches where required and to clinical colleagues
where there is an unaddressed clinical need.
Regularly liaise with the range of
multidisciplinary professionals and colleagues involved in the persons care,
facilitating a co-ordinated 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.
fIdentify when action or additional support is
needed, alerting a named clinical contact in addition to relevant
professionals, and highlighting any safety concerns.
Record what interventions are used to support
people, and how people are developing on their health and care journey.
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 people, their families and carers to capture key information, while
tracking of the impact of care co-ordination on their health and wellbeing.
Record and collate
information according to agreed protocols and contribute to evaluation reports
required for the monitoring and quality improvement of the service.
3. Supervision/professional development
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.
Access relevant GPs to discuss patient related
concerns, and be supported to follow appropriate safeguarding procedures
Miscellaneous
Establish strong working relationships with GPs and
practice teams and work collaboratively with other care co-ordinators, 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.
cDemonstrate 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.
Contribute to the wider aims and objectives of the
PCN to improve and support primary care.
Job description
Job responsibilities
Enable access to personalised care and support
Take referrals or proactively identify people who
could benefit from support through care co-ordination.
Have a positive, empathetic and responsive
conversations with people and their families and carer(s), about their needs.
Increasing patients understanding of how to manage
and improve health and wellbeing by offering advice and guidance.
Develop an in-depth knowledge of the local health
and care infrastructure and know how and when to enable people to access
support and services that are right for them.
Use tools to measure peoples levels of knowledge,
skills and confidence in managing their health and tailor support to them
accordingly.
Support people to develop and implement
personalised care and support plans.
Review and update personalised care and support
plans at regular intervals.
Ensure personalised care and support plans are
communicated to the GP and any other professionals involved in the persons
care and uploaded to the relevant online care records, with activity recorded
using the relevant SNOMED codes.
Co-ordinate and integrate careMake and manage appointments for patients, related
to primary, secondary, community, local authority, statutory, and voluntary
organisations.
Help people transition seamlessly between secondary
and community care services, conducting follow-up appointments, and supporting
people to navigate through the wider health and care system.
Refer onwards to social prescribing link workers
and health and wellbeing coaches where required and to clinical colleagues
where there is an unaddressed clinical need.
Regularly liaise with the range of
multidisciplinary professionals and colleagues involved in the persons care,
facilitating a co-ordinated 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.
fIdentify when action or additional support is
needed, alerting a named clinical contact in addition to relevant
professionals, and highlighting any safety concerns.
Record what interventions are used to support
people, and how people are developing on their health and care journey.
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 people, their families and carers to capture key information, while
tracking of the impact of care co-ordination on their health and wellbeing.
Record and collate
information according to agreed protocols and contribute to evaluation reports
required for the monitoring and quality improvement of the service.
3. Supervision/professional development
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.
Access relevant GPs to discuss patient related
concerns, and be supported to follow appropriate safeguarding procedures
Miscellaneous
Establish strong working relationships with GPs and
practice teams and work collaboratively with other care co-ordinators, 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.
cDemonstrate 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.
Contribute to the wider aims and objectives of the
PCN to improve and support primary care.
Person Specification
Experience
Essential
- Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement
- Experience of data collection and using tools to measure the impact of services
- understanding of how to use System 1
- experience of working in primary care
Desirable
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
- Experience of working within multi - professional team environments
- Experience of supporting people, their families and carers in a related role
- Experience or training in personalised care and support planning
Other
Essential
- Access to own transport
- Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social
Qualifications
Essential
- GCSE A-C IN English and Maths
- Meets a Disclosure and Barring Service (DBS) reference standards and criminal record checks
Desirable
- Administration qualifications
Person Specification
Experience
Essential
- Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement
- Experience of data collection and using tools to measure the impact of services
- understanding of how to use System 1
- experience of working in primary care
Desirable
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
- Experience of working within multi - professional team environments
- Experience of supporting people, their families and carers in a related role
- Experience or training in personalised care and support planning
Other
Essential
- Access to own transport
- Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social
Qualifications
Essential
- GCSE A-C IN English and Maths
- Meets a Disclosure and Barring Service (DBS) reference standards and criminal record checks
Desirable
- Administration qualifications
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.
