Job responsibilities
Care
Coordinators are a key part of the Primary Care Network (PCN) multidisciplinary
team. They often work alongside Social Prescribing Link Workers and Health
& Wellbeing Coaches to provide an all-encompassing approach to personalised
care and promote and embed the personalised care approach across Primary Care
Network(s).
Care
Coordinators will have access to ongoing supervision, skills development, and
support so they are able to further build their skills and experience within
the role.
Please note that this role is a
non-clinical role.
Key role requirements
Provide
one-to-one support for people of the age of 50 or above with one or more health/care
needs, supporting patients needs based on what is important to them, with the
aim of: improving peoples knowledge, skills, confidence in managing their
condition/s, empowering people to manage their own health and improve their
health outcomes and support them in making changes relating to their
health/social requirements
Manage and
prioritise a caseload, in accordance with the needs, priorities and support
required by individuals in the caseload. It is vital that you have a strong
awareness and understanding of when it is appropriate or necessary to refer
people back to other health professionals/agencies, when the person needs are beyond
the scope of the health and wellbeing coach role e.g. when there is a mental
health need requiring the patient to be referred to an appropriately qualified
practitioner.
Work as part of a
multidisciplinary multi-agency team.
Ensure that GPs,
practice nurses, practice pharmacists and other members of the primary care
team understand the Health and Wellbeing Coach role, how to refer to them, and
which patients may particularly benefit from health coaching.
Support local
health, social care and voluntary sector professionals to make appropriate
referrals to the service.
Attend and
contribute to team, practice, and PCN meetings and events as required by the
service.
Work flexibly,
adapting to the needs of the service and client group while maintaining the
integrity of the role.
Participate in regular supervision and
continual learning. This may include, but is not limited to, any or all the
following:
o
Regular contact
with service supervisor
o
Refresher
training sessions
o
Buddying with
peers
o
Peer support
sessions
o
1:1 support from
a practitioner with more health coaching experience
o
Action Learning
Sets
o
e-learning to
revisit or deepen training
o
On-going
improvements to systems and processes
Collect and
collate service user experience and information that measures the impact of our
service and support
Key Tasks
1. Provide personalised support
Meet people on a
one-to-one face-to-face or by phone groups
Give people time
to tell their stories and focus on what matters to the them, not whats the
matter with them;
Build trust and
respect with the person, providing non-judgemental and non-discriminatory
support, respecting diversity and lifestyle choices;
Work from a
strength-based approach focusing on a persons assets;
Use a structured
framework/model approach to support individuals and identify whats important
to them; set personal goals and appropriate steps; build skills and confidence
to achieve goals; and use problem-solving to work through challenges;
Work with the
principles of self-management to actively support:
o shared decision making with healthcare professionals;
o effective engagement with personalised health and care
plans;
o proactive engagement with self-management education
and peer support;
o proactive engagement with social prescribing,
connecting people to community-based activities which support their health and
wellbeing if required;
o proactive engagement with individually sourced
activities and support
2. Referrals
As part of the
PCN multidisciplinary team, build relationships with staff in GP practices
within the local PCN, attending relevant multidisciplinary meetings, giving
information and feedback on health coaching;
Be proactive in
developing strong links with all local organisations and work in partnership
with them to encourage referrals, recognising what they need to be confident in
the service to make appropriate referrals;
Provide referral
organisations with regular updates including information on how to encourage
appropriate referrals and seek regular feedback to improve on service delivery
where appropriate
Be proactive in
encouraging equality and inclusion and case-finding, through self-referrals and
connecting with all diverse local communities, particularly those communities
that statutory bodies may find hard to reach.
General Tasks
1. Gathering and Reporting Information
Work sensitively
with people, their families and carers to gather key information whilst
supporting patients health and wellbeing;
Encourage patients,
their families and carers to provide feedback and to share their stories about
the impact of support provided to them
Support referral
organisations to provide appropriate information about the person they are
referring. Provide appropriate feedback to referral agencies about the people
they referred
2. Supervision/Professional development
Have access to
relevant GPs to discuss patient related concerns, and be supported to follow
appropriate safeguarding procedures;
Know and adhere
to organisational policies and procedures, including confidentiality,
safeguarding, vulnerable adults, lone working, information governance,
equality, diversity and inclusion training and health and safety.
3. Miscellaneous
Establish strong
working relationships with GPs and practice teams and work collaboratively with
Health and Wellbeing Coaches, other Care Coordinators and Social Prescribing
Link Workers, supporting each other, respecting each others views and meeting
regularly as a team;
Act as a champion
for frailty aged 50+ years and above as a part of the PCNs proactive frailty
reviews.
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 review risks and issues that could
impact on service delivery - 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 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.
Confidentiality
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 carers,
staff, and other healthcare workers.
They may also have access to information relating to any part of the
business organisation. All such
information from any source is to be regarded as strictly confidential.
Information
relating to staff, patients, carers, colleagues, other healthcare workers or
the business of the Practice may only be divulged to authorised persons in
accordance with Alliance policies and procedures, and the protection of
personal and sensitive data.
Health
& Safety
The
post-holder will assist in promoting and maintaining their own and others
health, safety and security as defined in the Alliances Health & Safety
Policy to include
Identifying
the risk involved in work activities and undertaking such activities in a way
that manages those risks
Ensure all
accidents are reported and investigated, follow up action taken as necessary
Maintain
training in line with local policies.
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 recognizes the importance of peoples rights, interpreting them in a
way that is consistent with current legislation
Respecting
the privacy, dignity, needs and beliefs of patients, carers and colleagues
Behaving in
a manner which is welcoming to and of the individual, is non-judgemental and
respects their circumstances, feelings, priorities and rights.
Quality
The
post-holder will strive to maintain quality and will:
Alert other
team members to issues of quality and risk
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 enhanced the teams performance
Work
effectively with individuals in other agencies to meet patients needs
Effectively
manage own time, workload and resources.
Contribution
to the Implementation of Services
The post
holder will:
Apply
practice and PCN policies, standards and guidance.
Discuss
with other members of the team how the policies, standards and guidelines will
affect own work.
Participate
in any audits where appropriate.
Communication
The
post-holder should recognize the importance of effective communication within
the team and will strive to:
Communicate
effectively with other team members.
Communicate
effectively with patients and carers.
Recognise
peoples needs for alternative methods of communication and respond
accordingly.
This job description is intended as a basic guide to
the scope and responsibilities of the post and is not exhaustive. It will be
subject to regular review and amendment as necessary in consultation with the
post holder.
