Care Coordinator Upper Calder Valley

Job description

Job responsibilities

1. Undertake work in line with PCN directed priorities.

2. Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids.

3. Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance.

4. Raise awareness of health promotion and NHS health checks in practices.

5. Support national screening programmes.

6. Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact.

7. Direct liaison with multi agencies to coordinate care for patients.

8. Refer to PCN social prescribing link workers where a patient is identified as potentially benefitting from this service.

9. To support patient/carer contact roles and collate patient and carer feedback on their experiences.

10. Support Quality and Outcome Frameworks and other DES/LES specifications.

11. Maintain and develop engagement with all practice staff and encourage best practice.

12. Act as the first port of call for patients, in their caseload in relation to their care.

13. Bring together all of a persons identified care and support needs and explore their options to meet these into a single personalise care and support plan (PCSP), in line with PCSP best practice.

14. Help people to manage their needs, answering their queries and support them to make appointments.

15. Support people to take up training, employment, and access appropriate benefits where eligible.

16. Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation.

17. Ensure that people have good quality information to help them make choices about their care.

18. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including using the Patient Activation Measure.

19. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.

20. Explore and assist people to access personal health budgets where appropriate.

21. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles.

22. Support the coordination and delivery of care home MDTs within PCNS ensuring the enhanced health in care homes model is delivered.

23. Supporting residents in care homes/LD homes ensuring personalised care is delivered through collaborative working between health, social care, voluntary, community and social enterprise sector and care home partners.

24. 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.

25. In the performance of the duties outline in this job description the post-holder may have access to confidential information relating to patients, their carers, practice, or staff information. All such information from any source is to be regarded as strictly confidential.

26. Information relating to patients, carers, colleagues, or member practices may only be divulged to authorised person in accordance with PGPA policies and procedures relating to confidentiality and the protection of personal and sensitive data, or under the guidance of your manager.

27. Where required competently carry out all elements of the health check (A full check involves measurement of body mass index and waist circumference, pulse rate, blood pressure, height and weight, QRISK measurement, blood glucose, blood lipid, smoking and alcohol) and where required refer for further clinical advice

28. Additional Duties

General

To maintain up to date knowledge of legislation, national and local policies and issues in relation to the specific client group, mental health and community care delivery.

To comply with the Professional Codes of Conduct and to be aware of changes in these. To maintain up to date knowledge of all relevant legislation and local policies and procedures implementing this.

To ensure that all duties are carried out to the highest standard and in accordance with currently quality initiatives within the work area.

To comply with all relevant organisations policies, procedures and guidelines, including those relating to Equal Opportunities, Health and Safety and Confidentiality of Information and to be aware of any changes in these.

To comply at all times with the PGPAs Information Governance related policies. Staff are required to respect the confidentiality of information about staff, patients and PGPA business and in particular the confidentiality and security of personal identifiable information in line with the Data Protection Act. All staff is responsible for ensuring that any data created by them is timely, comprehensive, accurate, and fit for the purposes for which it is intended.

Equality & Diversity

PGPA is committed to equality and diversity and works hard to make sure all staff and service users have access to an environment that is open and a free from discrimination. As an organisation, we value the diversity of our staff and service users, and therefore recognise and appreciate that everyone associated with PGPA is different and so should be treated in ways that are consistent with their needs and preferences.

Therefore all staff are required to be aware of the organisations Equality and Diversity Policy and the commitments and responsibilities we have to:

Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act.

Advance equality of opportunity between people who share a protected characteristic and those who do not.

Foster good relations between people who share a protected characteristic and those who do not. We firmly believe that it makes good business sense to have a workforce representative of the communities we serve and so encourage applications from all sections of the community.

Person Specification

Qualifications

Essential

• ECDL or equivalent Diploma/HNC level (or relevant experience)
• NVQ Level 2 Business Administration (or relevant experience)
• Demonstrable commitment to professional and personal continuous development.

Desirable

• Training in motivational coaching and interviewing or equivalent.
• Knowledge of primary care IT Systems Qualified to NVQ level 2 in Health and Social Care.

Experience

Essential

• Experience of working with healthcare professional and or previous experience in the NHS or social care or relevant field (including unpaid work)
• Experience of data collection and providing monitoring information to assess the impact of services.
• Experience of partnership/collaborative working and of building relationships across a variety of organisations.
• Experience of working with or in general practice.
• Working in a multi-disciplinary setting where influence and negotiation is required.
• Knowledge/familiarity with medical terminology.

Desirable

• Experience of supporting people, their families and carers in a related role (including unpaid work).
• Experience in use of databases.
• Vulnerable adults awareness.
• Experience of care of the elderly.

Skills/Knowledge

Essential

• Knowledge of the personalised care approach.
• Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports.
• Creative problem solver and willing to search for hard-to-find information.
• Meets DBS reference standards and has a clear criminal record in line with the law on spend convictions.
• Access to own transport and ability to travel across the locality on a regular basis.
• Continued commitment to improve skills and ability in new areas of work.

Desirable

• Knowledge of general practice clinical systems, such as, EMIS and SystmOne Ability to read large amounts of information and extract the salient points.
• To analyse data and report on findings.

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

Pennine GP Alliance

Address

Todmorden Health Centre

Lower George Street

Todmorden

Lancashire

OL14 5RN

Employer's website

https://penninegpa.co.uk/ (Opens in a new tab)