Job summary
Full time 10am 6pm
Care coordinators play a varied and
important role within our practices. Their
primary function is to work with along side and with our clinical triage team
to coordinate the care for our practice patient population and ensure the right
care at the right time.
Care coordinators review patients
needs and help them access the services and support they require to understand
and manage their own health and wellbeing, referring to social prescribing link
workers, health and wellbeing coaches, and other professionals where
appropriate.
This role is intended to become an
integral part of the practices multidisciplinary team, working alongside social
prescribing link workers and health and wellbeing coaches to provide an
all-encompassing approach to personalised care and promoting and embedding the
personalised care approach across the PCN. There may be a need to work remotely
depending on the requirements of the role.
Please note that the role of a care
coordinator is not a clinical role.
Main duties of the job
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.
Work collaboratively with GPs and other primary care
professionals within the practice 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 at our PCN or
within our community service.
Work with people, their families, carers and healthcare
team members to encourage effective help-seeking behaviours.
Support our digital team in developing communication
channels between GPs, people and their families and carers and other agencies.
Maintain records of referrals and interventions to
enable monitoring and evaluation of the service. Conduct follow-ups on communications from out of
hospital and in-patient services.
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identifying and updating missing or out-of-date information about the persons circumstances.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.
About us
We provide General Medical
Services to our patients from 2 sites in Southend:
Thorpe Bay surgery, Tyrone Road
Southend-on-Sea SS1 3HD
Tel 01702 582670
North Shoebury Surgery,
Frobisher Way, Shoeburyness, Essex SS3 8UTTel 01702 297976
Working together in
partnership with our Primary Care Network to deliver services to their patient population across both
practice sites, the practice is clinically lead by a GP and an Advanced Clinical
Practitioner, the partners are supported by a diverse clinical team made up of
salaried GPs and part time locum GPs, Advanced Nurse Practitioners, Associate
Nurse Practitioners, Prescribing Paramedics, Practice nurses, GP Nurse
Assistant, Health Care Assistants, a Lead Pharmacy Technician, Pharmacy
Technicians, and a Prescription Clerks.
The administration team
comprise of Care Navigators, Care Co-Ordinators, Medical secretaries, administration
staff, Assistant Manager, Practice Manager, Primary care Development Manager
and Business Manager with a list size in excess of 15,500 patients.
We are very proud to be a Training Practice
supporting GP and Nurse Training across South East Essex.
Whilst our practice
registration is growing, we strive to provide high quality, safe, efficient,
and effective service within the resource allocated to the practice. With particular focus on the prevention of
disease by promoting health and wellbeing, offering care and advice to our
patients.
Job description
Job responsibilities
Enable access to personalised care and support
Take referrals for individuals or proactively identify
people who could benefit from support through care coordination.
Have a positive, empathetic and responsive conversation
with the person and their family and carer(s) about their needs.
Work towards increasing patients understanding of how
to manage and develop health and wellbeing through 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 to 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 relevantSNOMED codes.
Coordinate and integrate care
Making and managing appointments for patients, related
to primary, secondary, community, local authority, statutory, and voluntary
organisations
Refer onwards to social prescribing link workers and
health and wellbeing coaches where required.
Regularly liaise with the range of multidisciplinary
professionals and colleagues involved in the persons 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 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.
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 coordination
on their health and wellbeing.
Encourage people, their families and carers 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.
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 practice.
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 policies and procedures.
Contribute to the wider aims and objectives of the practice
and our PCN to improve and support primary care.
Job description
Job responsibilities
Enable access to personalised care and support
Take referrals for individuals or proactively identify
people who could benefit from support through care coordination.
Have a positive, empathetic and responsive conversation
with the person and their family and carer(s) about their needs.
Work towards increasing patients understanding of how
to manage and develop health and wellbeing through 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 to 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 relevantSNOMED codes.
Coordinate and integrate care
Making and managing appointments for patients, related
to primary, secondary, community, local authority, statutory, and voluntary
organisations
Refer onwards to social prescribing link workers and
health and wellbeing coaches where required.
Regularly liaise with the range of multidisciplinary
professionals and colleagues involved in the persons 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 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.
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 coordination
on their health and wellbeing.
Encourage people, their families and carers 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.
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 practice.
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 policies and procedures.
Contribute to the wider aims and objectives of the practice
and our PCN to improve and support primary care.
Person Specification
Additional Requirements
Essential
- ECDL or equivalent IT skill & knowledge
- Understanding of, and commitment to, equality, diversity and inclusion.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Ability to recognise and work within limits of competence and seek advice when needed.
- Meets DBS reference standards and criminal record checks.
- Willingness to work flexible hours when required to meet work demands.
Desirable
- Knowledge of the personalised care approach.
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Knowledge of how the NHS works, including primary care and PCNs.
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes.
- Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social.
Qualifications
Essential
- GCSE Grade A to C in English Maths
Desirable
- GCSE Grade A to C in Biology
- Qualified to NVQ level 2 in Health and Social Care
Experience
Essential
- Experience of data collection and using tools to measure the impact of services.
- Experience of maintaining filing systems & collating information.
- Proficient using Microsoft Word, Excel and Outlook
- Clinical System Administration
Desirable
- Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement.
- 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.
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
Person Specification
Additional Requirements
Essential
- ECDL or equivalent IT skill & knowledge
- Understanding of, and commitment to, equality, diversity and inclusion.
- Strong organisational skills, including planning, prioritising, time management and record keeping.
- Ability to recognise and work within limits of competence and seek advice when needed.
- Meets DBS reference standards and criminal record checks.
- Willingness to work flexible hours when required to meet work demands.
Desirable
- Knowledge of the personalised care approach.
- Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
- Knowledge of how the NHS works, including primary care and PCNs.
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes.
- Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social.
Qualifications
Essential
- GCSE Grade A to C in English Maths
Desirable
- GCSE Grade A to C in Biology
- Qualified to NVQ level 2 in Health and Social Care
Experience
Essential
- Experience of data collection and using tools to measure the impact of services.
- Experience of maintaining filing systems & collating information.
- Proficient using Microsoft Word, Excel and Outlook
- Clinical System Administration
Desirable
- Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement.
- 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.
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
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.
