Frailty Care Coordinator

Job description

Job responsibilities

Care Coordinators will:

• Provide coordination and navigation for people and their carers across health and care services, working closely with primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.

• Work sensitively with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.

• 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.

• To be able to manage a patients needs appropriately documenting all consultations within the patients notes.

• Listen to patients needs and help to manage their needs through answering queries and sign posting to the relevant services.

• Contact and organise clinical reviews for all patients with a new diagnosis or declining health with a GP/ACP/paramedic where appropriate.

• Liaise with appropriate GPs and professionals when appropriate.

• Build effective relationships with each practice and its staff.

• To run weekly clinical system searches for frailty patients contacting the patient to arrange appointments.

• Supporting the clinicians and patients to ensure coordination of repeat medications is complete in a prompt manner. This includes tracking prescription requests, liaising with homes and pharmacies and providing EMIS admin support to prescribing colleagues Contribute to increasing performance of NHS contracts

• Contribute to the evaluation of the service, collate and input timely data and suggest/implement service improvements.

• Keeping up to date with National/Local Frailty Strategies.

• Ability to work within a team and independently.

• Undertake any other duties deemed appropriate by the PCN Manager and clinical teams.

• Complete annual mandatory training as required.

• Enrol as a member of the Personalised Care Institute to receive up to date training and the opportunity to join webinars.

• Participation in an annual individual performance review, including taking own responsibility for maintaining record of own personal record.

Provide personalised support:

• Work with the patient, their families and carers and consider how they can all be supported by services available to them.

• Bring together a persons identified care needs and explore their options to meet these within a simple coproduced personalised care and support plan, including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.

• Seek advice and support from the Clinical Leads and/or identified individual(s) to discuss patient related concerns (referring the patient back to the GP or other suitable health professional if required).

Data capture:

• Work sensitively with people, their families and carers to capture key information, enabling comprehensive and accurate records of support.

• Encourage people, their families and carers to provide feedback and engage fully in the care coordination process.

Other:

• Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.

General:

• To undertake any other duties commensurate with the role, within the bounds of his/her own competence.

• To work across practice sites as required.

• To work flexibly to accommodate evening meetings as required.

• To visit patients in their own homes or care homes .

Confidentiality

• In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately;

• In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their careers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential.

Health & Safety

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety Policy, to include:

• Using personal security systems within the workplace according to practice guidelines;

• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks;

• Making effective use of training to update knowledge and skills;

• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards;

• Reporting potential risks identified.

Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

• Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation.

• Respecting the privacy, dignity, needs and beliefs of patients, carers, and colleagues.

Personal/Professional Development

In addition to maintaining continued education through attendance at any courses and/or study days necessary to ensure that professional development requirements are met, the post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include:

• Participation in an annual individual performance review, annual Appraisal including taking responsibility for maintaining a record of own personal and/or professional development.

• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

Quality

The post-holder will strive to maintain quality within the practice, and will:

• Alert other team members to issues of Clinical Governance issues, quality and risk; participate in Significant Event Analysis reviews

• Assess own performance and take accountability for own actions, either directly or under supervision.

• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.

• Work effectively with individuals in other agencies to meet patients needs.

• Effectively manage own time, workload, and resources. He/she will also contribute to the overall teamwork of the PCN, putting the needs of the PCN first.

Contribution to the planning and implementation of services

The post-holder will:

• Apply practice policies, standards and guidance;

• Discuss with other members of the team how the policies, standards and guidelines will affect own work;

• Participate in audits where appropriate.

• Work with the Lead GP(s) to achieve standards of quality and performance standards, without compromising levels of patient healthcare.

• Contribute towards the development and implementation of new standards, policies and procedures that are/will be required of GP Practices now and in the future (as directed by NHS/ DoH/, new legislation etc.)

Communication

• Be able to effectively communicate at all levels of the organisation to a variety of health professionals, users and carers, independent and voluntary sectors to provide the best outcomes for users of the services.

• Provide interface between hospital, primary, community and social settings, participate where appropriate in clinical meetings relating to patient care and outcomes

• Communicate effectively with patients and carers

• Be able to keep accurate contemporaneous documentation, both written and computerised, inpatient records and will need to be familiar with EMIS Web.

• Recognise peoples needs for alternative methods of communication and respond accordingly

Equal Opportunities

At Vertis Health we want to build a diverse workplace, and so and encourage women, people of colour, LGBTQIA individuals, people with disabilities, members of ethnic minorities, foreign-born residents, older members of society, and others from minority groups and diverse backgrounds to apply.

We do not discriminate on the basis of race, gender, religion, colour, national origin, sexual orientation, age, marital status, veteran status, or disability status. All Vertis employees and contractors are responsible for maintaining a work culture free from discrimination and harassment by treating others with kindness and respect.

Clinical Governance

• To participate and operate within the clinical governance framework for the organisation at all times, incorporating service users and carers, audit, guidelines and risk management.

• To actively participate in the practices, becoming familiar with and abiding by its plans, policies and procedures.

This job description may be reviewed in the light of changing organisational and service needs. Any changes will be fully discussed with the post holder. The post holder may also be required to carry out other work appropriate to the grade of the post.

LOCATION

The role will mostly be based in Worcester City Primary Care Network member practices and will require travel amongst PCN member practices and patients' homes across the network. The postholder should be flexible in their working hours, which may include some evening and weekend work.

Person Specification

Qualifications

Essential

• Good general standard of education

Desirable

• Administration related qualification

Other Requirements

Essential

• This role will be based within either the Acute visiting team or Care Home team at Worcester City Primary Care Network, working alongside GPs and the members of the working group
• A willingness to work flexibly

Experience

Essential

• Significant previous experience of working in a proactive administrative role.
• Working within a social care/health or related environment in a delivery or front face role
• Working with people who are vulnerable or face disadvantage
• Working in an empathetic and empowering way
• Working with databases and assimilating and reporting information
• Experience of working in a dynamic and creative way, solving problems and prioritising work

Desirable

• Experience of working in a multi-disciplinary team
• Experience of gathering information to determine needs/expectations

Skills

Essential

• Excellent administration skills
• Telecommunication skills
• High level communication and interpersonal skills
• Excellent organisational skills with a logical and structured approach to your work
• Ability to respond to changing needs, pressures and demands and prioritise accordingly
• Strong IT skills to include EMIS and Microsoft office, in particular excel and word
• Ability to build effective working relationships
• Ability to analyse and interpret data
• Evidence of working within a team environment
• Maintaining boundaries and ensuring clarity and understanding of the role
• Ability to self-manage and be creative in your approach to problem solving
• Ability and confidence to work on own initiative

Desirable

• Use of IT systems including EMIS, Care Notes, Microsoft office, email and database systems (external and internal)

Knowledge

Essential

• Knowledge and understanding of the health and social care sector
• Knowledge of safeguarding, confidentiality and GDPR and the best practice approaches
• Equal Opportunities and Diversity

Desirable

• Understanding and knowledge of the role, practice, and principles of care planning
• Knowledge of EMIS database and application within an operational/administrative role
• Social and health care systems and processes
• A working knowledge of relevant legislation including Data Protection

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

Vertis Health

Address

Henwick Halt Medical Centre

1 Ingles Drive

Worcester

WR2 5HL

Employer's website

https://www.vertishealth.org.uk/ (Opens in a new tab)