Job summary
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 them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.
Main duties of the job
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 to other health
professionals within the PCN.
Support the
coordination and delivery of multidisciplinary teams with the PCN.
Raise
awareness of how to identify patients who may benefit from shared decision
making and support PCN staff and patients to be more prepared to have shared
decision-making conversations.
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
Identify
unpaid carers and help them access services to support them
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;
Work 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
About us
The East Lancashire Alliance is a network of 9 PCNs covering 48 GP practices covering a population of over 390,000 patients across East Lancashire. Patients are at the heart of everything we do and we pride ourselves in ensuring our patients feel safe, supported, communicated with and respected at a time when they may be feeling vulnerable. The Alliance are proud to represent our member practices and to champion our Primary Care Partners, by working with local general practice, and other system partners in the provision of patient centred, local healthcare services.
Each practice has a close-knit team of staff who collectively seek to improve the health of their patient populations.
East Lancashire is one of the world's most innovative, original and exciting places to live and work. From the beauty of the surrounding countryside, to the heart of the vibrant inner Towns and Villages with great shopping, entertainment and dining options. Wherever you go you will experience a great northern welcome with people famed for their warmth, humour and generosity.
Job description
Job responsibilities
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
them 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
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.
Care
coordinators could potentially provide time, capacity and expertise to support
people in preparing for or following-up clinical conversations they have with
primary care professionals to enable them to be actively involved in managing
their care and supported to make choices that are right for them. Their aim is
to help people improve their quality of life.
They will be
caring, dedicated, reliable and person-focussed and enjoy working with a wide
range of people. They will have good written and verbal communication skills
and strong organisational and time management skills. They will be highly
motivated and proactive with a flexible attitude, keen to work and learn as
part of a team and committed to providing people, their families and carers
with high quality support.
This role is
intended to become an integral part of the PCNs 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.
Please note that the
role of a care coordinator is not a clinical role
Some of the key tasks will include the following
1. Enable access to personalised care and support
a. Take referrals for individuals
or proactively identify people who could benefit from support through care
coordination;
b. Have a positive, empathetic
and responsive conversation with the person and their family and carer(s) about
their needs;
c. Work towards increasing
patients understanding of how to manage and develop health and wellbeing
through offering advice and guidance;
d. 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;
e. Use tools to measure peoples
levels of knowledge, skills and confidence in managing their health and to
tailor support to them accordingly. f. Work with the wider PCN, MDTs to look at
how carers can support people - this could include the initial identification
of carers onto the carer register
h. Review and update personalised
care and support plans at regular intervals
i. 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
For further information, please refer to the Job description found in the 'Supporting Documents' section.
Job description
Job responsibilities
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
them 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
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.
Care
coordinators could potentially provide time, capacity and expertise to support
people in preparing for or following-up clinical conversations they have with
primary care professionals to enable them to be actively involved in managing
their care and supported to make choices that are right for them. Their aim is
to help people improve their quality of life.
They will be
caring, dedicated, reliable and person-focussed and enjoy working with a wide
range of people. They will have good written and verbal communication skills
and strong organisational and time management skills. They will be highly
motivated and proactive with a flexible attitude, keen to work and learn as
part of a team and committed to providing people, their families and carers
with high quality support.
This role is
intended to become an integral part of the PCNs 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.
Please note that the
role of a care coordinator is not a clinical role
Some of the key tasks will include the following
1. Enable access to personalised care and support
a. Take referrals for individuals
or proactively identify people who could benefit from support through care
coordination;
b. Have a positive, empathetic
and responsive conversation with the person and their family and carer(s) about
their needs;
c. Work towards increasing
patients understanding of how to manage and develop health and wellbeing
through offering advice and guidance;
d. 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;
e. Use tools to measure peoples
levels of knowledge, skills and confidence in managing their health and to
tailor support to them accordingly. f. Work with the wider PCN, MDTs to look at
how carers can support people - this could include the initial identification
of carers onto the carer register
h. Review and update personalised
care and support plans at regular intervals
i. 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
For further information, please refer to the Job description found in the 'Supporting Documents' section.
Person Specification
Qualifications
Essential
- Proficient in MS Office and web -based services
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
- Experience of working within multi - professional team environments
-
- Experience of supporting people, their families and carers in a related role
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
Personal qualities and attributes
Essential
- Personal qualities and attributes
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
- Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from diverse communities
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
- Ability to identify risk and assess / manage risk when working with individuals
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
- Ability to work from an asset-based approach, building on existing community and personal assets
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- Ability to demonstrate personal accountability, emotional resilience and work well under pressure
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- High level of written and verbal communication skills
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
- Ability to provide motivational coaching to support peoples behaviour change
Person Specification
Qualifications
Essential
- Proficient in MS Office and web -based services
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
- Experience of working within multi - professional team environments
-
- Experience of supporting people, their families and carers in a related role
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
Personal qualities and attributes
Essential
- Personal qualities and attributes
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
- Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from diverse communities
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
- Ability to identify risk and assess / manage risk when working with individuals
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner
- Ability to work from an asset-based approach, building on existing community and personal assets
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- Ability to demonstrate personal accountability, emotional resilience and work well under pressure
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- High level of written and verbal communication skills
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
- Ability to provide motivational coaching to support peoples behaviour change
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
