Job summary
Are you passionate about making a real difference
to older people and those living in care homes? Do you thrive on bringing
people together and ensuring patients receive the right support at the right
time?
IMP Healthcare are recruiting a Care Coordinator to
join our Ageing Well team, supporting the Enhanced Health in Care Homes (EHCH)
and housebound services. Working alongside GPs, ANPs and the wider
multidisciplinary team, you will proactively manage a caseload of patients with
complex or changing needs.
You will join a supportive,
collaborative team committed to improving outcomes for vulnerable patients
while offering structured supervision and opportunities for development.
Main duties of the job
The Care Coordinator will work alongside GPs, ANPs and the wider multidisciplinary team to proactively identify and manage a caseload of patients, particularly those living in care homes or with complex needs. The role involves developing, implementing and regularly reviewing personalised care and support plans, ensuring they are accurately recorded and shared with relevant professionals.
You will coordinate care across primary, community and secondary services, support patients and carers to navigate the health and care system, and promote shared decision-making. The postholder will liaise regularly with care homes, families and partner organisations to ensure a joined-up approach, escalate concerns where required, and participate in MDT meetings.
Accurate documentation, use of clinical systems and contribution to service improvement are key components of the role, alongside maintaining strong working relationships across the PCN.
About us
IMP Healthcare is a Primary Care Network (PCN) comprising nine GP practices working collaboratively to deliver high-quality, integrated healthcare to a population of approximately 74,000 patients across North Lincolnshire and surrounding areas.
The PCN brings together general practice teams and a wide multidisciplinary workforce to provide proactive, patient-centred care closer to home. Key areas of focus include Enhanced Health in Care Homes (EHCH), anticipatory care, frailty, long-term condition management and improving access to primary care services.
IMP Healthcare is committed to reducing health inequalities, improving population health outcomes and supporting patients to remain well and independent within their communities. Through collaborative working, service innovation and strong clinical leadership, the organisation continues to develop responsive services aligned to national priorities and local population need.
Job description
Job responsibilities
The Care Coordinator
will support the delivery of the Ageing Well service within the Primary Care
Network, working proactively with patients living with frailty, long-term
conditions and complex health and social needs.
Clinical
Coordination & Caseload Management
- Proactively identify and manage a
defined caseload of patients within the Ageing Well cohort.
- Coordinate and organise staff rotas
on SystmOne for ANP, Frailty Nurse, Occupational Therapist and Pharmacist
clinics.
- Contact patients via their
preferred communication method to invite them into the service and arrange
appointments.
- Support seamless transitions
between primary, community and secondary care.
- Liaise regularly with GPs, ANPs,
pharmacists, social prescribers and community teams to ensure coordinated
care delivery.
- Actively participate in
multidisciplinary team (MDT) meetings and support preparation and
follow-up actions.
Personalised
Care & Support Planning
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
following the NHS Comprehensive Care
Model. See also YouTube NHS Comprehensive
Personalised Care Model Explainer Animation.
- Conduct home visits for housebound
patients where appropriate.
- Review and update care plans at
agreed intervals.
- Promote shared decision-making
conversations.
- Ensure care plans are communicated
to relevant professionals and recorded accurately in clinical systems.
- Escalate any clinical concerns to
supervising clinician.
Navigation
& Signposting
- Develop an in-depth understanding
of local health, community and voluntary sector services.
- Support appropriate onward
referrals to social prescribing link workers and other services.
- Help patients navigate the wider
health and care system.
- Identify when additional support or
intervention is required and raise concerns promptly.
Digital
& Data Responsibilities
- Maintain accurate, contemporaneous
documentation within SystmOne.
- Record activity using appropriate
SNOMED/read codes to support reporting and audit.
- Support data quality improvement
within the Ageing Well service.
- Use digital systems to track
patient progress and outcomes.
- Contribute to monitoring service
activity and performance metrics.
Governance,
Safety & Compliance
- Adhere to safeguarding policies Adults & Children and escalate concerns appropriately.
- Follow lone working procedures
during home visits.
- Maintain patient confidentiality
and comply with information governance standards.
- Identify and report risks or
incidents in line with PCN policy.
- Participate in clinical supervision
sessions with supervising GP/ANP.
- Work within the defined scope of
the Care Coordinator role and avoid providing clinical advice beyond
competence.
Participate in the
management of patient complaints when requested to do so and participate in the
identification of any necessary learning brought about through incidents and
near-miss events.
Maintain a clean, tidy,
effective working area at all times
Service
Improvement & Development
- Identify service gaps and provide
feedback to improve delivery.
- Contribute to quality improvement
initiatives within the PCN.
- Support service monitoring through
accurate recording of interventions and outcomes.
- Assist in evaluation of patient
experience within the service.
Professional
Development
- Participate in regular one-to-one
supervision meetings.
- Engage in mandatory training and
ongoing professional development.
- Take part in annual appraisal and
objective setting.
- Work collaboratively with other
Care Coordinators across the PCN.
Outcome
Expectations
The
post-holder will contribute to:
- Increased completion of
personalised care plans.
- Improved frailty identification and
coding accuracy.
- Reduction in avoidable hospital
admissions where appropriate.
- Improved patient experience and
continuity of care.
- Effective MDT coordination and
follow-up.
In addition to the primary responsibilities,
the Patient Care Coordinator has the following wider responsibilities:
a.
Support
the delivery of QOF, incentive schemes, QIPP and other quality or cost
effectiveness initiatives
a.
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
b.
Duties
may vary from time to time without changing the general character of the post
or the level of responsibility
Duties may vary from
time to time without changing the general character of the post or the level of
responsibility
Job description
Job responsibilities
The Care Coordinator
will support the delivery of the Ageing Well service within the Primary Care
Network, working proactively with patients living with frailty, long-term
conditions and complex health and social needs.
Clinical
Coordination & Caseload Management
- Proactively identify and manage a
defined caseload of patients within the Ageing Well cohort.
- Coordinate and organise staff rotas
on SystmOne for ANP, Frailty Nurse, Occupational Therapist and Pharmacist
clinics.
- Contact patients via their
preferred communication method to invite them into the service and arrange
appointments.
- Support seamless transitions
between primary, community and secondary care.
- Liaise regularly with GPs, ANPs,
pharmacists, social prescribers and community teams to ensure coordinated
care delivery.
- Actively participate in
multidisciplinary team (MDT) meetings and support preparation and
follow-up actions.
Personalised
Care & Support Planning
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
following the NHS Comprehensive Care
Model. See also YouTube NHS Comprehensive
Personalised Care Model Explainer Animation.
- Conduct home visits for housebound
patients where appropriate.
- Review and update care plans at
agreed intervals.
- Promote shared decision-making
conversations.
- Ensure care plans are communicated
to relevant professionals and recorded accurately in clinical systems.
- Escalate any clinical concerns to
supervising clinician.
Navigation
& Signposting
- Develop an in-depth understanding
of local health, community and voluntary sector services.
- Support appropriate onward
referrals to social prescribing link workers and other services.
- Help patients navigate the wider
health and care system.
- Identify when additional support or
intervention is required and raise concerns promptly.
Digital
& Data Responsibilities
- Maintain accurate, contemporaneous
documentation within SystmOne.
- Record activity using appropriate
SNOMED/read codes to support reporting and audit.
- Support data quality improvement
within the Ageing Well service.
- Use digital systems to track
patient progress and outcomes.
- Contribute to monitoring service
activity and performance metrics.
Governance,
Safety & Compliance
- Adhere to safeguarding policies Adults & Children and escalate concerns appropriately.
- Follow lone working procedures
during home visits.
- Maintain patient confidentiality
and comply with information governance standards.
- Identify and report risks or
incidents in line with PCN policy.
- Participate in clinical supervision
sessions with supervising GP/ANP.
- Work within the defined scope of
the Care Coordinator role and avoid providing clinical advice beyond
competence.
Participate in the
management of patient complaints when requested to do so and participate in the
identification of any necessary learning brought about through incidents and
near-miss events.
Maintain a clean, tidy,
effective working area at all times
Service
Improvement & Development
- Identify service gaps and provide
feedback to improve delivery.
- Contribute to quality improvement
initiatives within the PCN.
- Support service monitoring through
accurate recording of interventions and outcomes.
- Assist in evaluation of patient
experience within the service.
Professional
Development
- Participate in regular one-to-one
supervision meetings.
- Engage in mandatory training and
ongoing professional development.
- Take part in annual appraisal and
objective setting.
- Work collaboratively with other
Care Coordinators across the PCN.
Outcome
Expectations
The
post-holder will contribute to:
- Increased completion of
personalised care plans.
- Improved frailty identification and
coding accuracy.
- Reduction in avoidable hospital
admissions where appropriate.
- Improved patient experience and
continuity of care.
- Effective MDT coordination and
follow-up.
In addition to the primary responsibilities,
the Patient Care Coordinator has the following wider responsibilities:
a.
Support
the delivery of QOF, incentive schemes, QIPP and other quality or cost
effectiveness initiatives
a.
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
b.
Duties
may vary from time to time without changing the general character of the post
or the level of responsibility
Duties may vary from
time to time without changing the general character of the post or the level of
responsibility
Person Specification
Experience
Essential
- Experience of working in a healthcare setting or in a public facing role. Excellent customer service skills.
Desirable
- Primary Care/General Practice experience
- Excellent IT and computer skills including SystmOne experience
Qualifications
Essential
- Good standard of secondary education, including Maths and English
Desirable
- Healthcare related qualification
Person Specification
Experience
Essential
- Experience of working in a healthcare setting or in a public facing role. Excellent customer service skills.
Desirable
- Primary Care/General Practice experience
- Excellent IT and computer skills including SystmOne experience
Qualifications
Essential
- Good standard of secondary education, including Maths and English
Desirable
- Healthcare related qualification
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
Additional information
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
