Care Coordinator - Live Well Team

Job description

Job responsibilities

About the Role

This Care Co-ordinator position within our 'Live Well' service represents an exciting opportunity to join SHaR PCN's innovative approach to supporting children, young people and families. You'll be working at the forefront of preventative healthcare, helping families achieve better health outcomes through early intervention and coordinated care that addresses what truly matters to them.

As part of our award-winning Primary Care Network spanning seven GP practices, you'll be embedded within our established Personalised Care Team. This role specifically focuses on our 'Live Well' work stream, which addresses the health and wellbeing needs of children, young people and families under 65, working proactively to optimise health outcomes through early intervention.

Key Responsibilities

First Contact and Relationship Building You'll serve as the first point of contact for families entering our Live Well pathway. This involves quickly establishing trusted, supportive relationships with each family or young person we work with. Your empathetic approach and excellent communication skills will be essential in creating an environment where families feel comfortable discussing their needs, concerns and aspirations for better health and wellbeing.

Assessment and Identification Following defined identification processes, you'll contact patients and families to conduct further triage and comprehensive assessments. This involves exploring their holistic care and support needs, identifying areas requiring intervention, and understanding what matters most to them. Your assessment skills will be crucial in ensuring families receive appropriate, timely support.

Personalised Care and Support Planning A central aspect of your role involves developing personalised care and support plans (PCSP) in line with best practice guidelines. You'll holistically bring together all identified care and support needs, exploring options to meet these within a single, coordinated plan based on what matters to each person and family. These plans will be regularly reviewed and updated to reflect changing needs and progress towards outcomes.

Care Co-ordination Across Sectors You'll work closely with multiple professionals across different sectors to co-ordinate support for patients and their families. This includes liaising with GPs, school nursing, health visitors, social prescribing link workers, children's social care, voluntary sector organisations and other PCN colleagues. Your role as a conduit will ensure families receive seamless, well-coordinated care that addresses their complex needs.

Ongoing Case Management You'll maintain ongoing relationships with families through regular check-ins, helping them make progress towards their planned outcomes and supporting them to access the right resources and services. This involves monitoring progress, identifying barriers, adapting plans as needed, and ensuring families feel supported throughout their journey.

Navigation and Information Provision Your role includes helping families navigate the often complex health and care system, answering queries, making and managing appointments, and ensuring people have good quality written or verbal information to help them make informed choices about their care. You'll develop in-depth knowledge of local health and care infrastructure to enable effective signposting and referrals.

Professional Collaboration and Communication Working within our integrated neighbourhood team, you'll collaborate with diverse health and care professionals, ensuring effective communication and information sharing. This includes preparing reports for clinical leads, participating in multidisciplinary team meetings, and ensuring care plans are communicated to GPs and other professionals involved in each person's care.

Service Development and Quality Improvement As part of implementing this new model of care, you'll provide valuable feedback on service delivery, help identify improvements and bottlenecks through process mapping, and contribute to developing effective communication channels between all stakeholders. Your insights will be crucial in adapting and improving the service to best meet patient needs.

Health Inequalities and Engagement You'll play a vital role in identifying health inequalities within our patient population and providing feedback on how engagement could be enhanced. This aligns with our commitment to reducing health disparities and ensuring equitable access to services for all families in our diverse communities.

Record Keeping and Information Governance You'll maintain accurate, appropriately coded records in patients' notes, including details of services they are referred to. All work will be conducted in accordance with information governance policies, maintaining confidentiality whilst ensuring appropriate information sharing to support coordinated care.

Working Environment

You'll be based across Ryedale and South Hambleton, working within a supportive team environment that values innovation, collaboration and professional development. The role offers flexibility whilst ensuring you have access to clinical supervision from the Senior Social Prescribing Link Worker for Live Well and support from our PCN Clinical Lead.

Our PCN is committed to creating an inclusive workplace that supports staff wellbeing and professional growth. You'll have access to comprehensive training opportunities, including programmes aligned with the Personalised Care Institute's core curriculum, and support for your ongoing professional development.

Career Development and Learning

This position offers significant opportunities for professional development within the expanding field of personalised care co-ordination. You'll be supported to undertake continual personal and professional development, with clear expectations around maintaining evidence of learning activities and participating in annual performance reviews.

The role provides exposure to cutting-edge healthcare delivery models and the opportunity to contribute to the development of this innovative service. You'll be working at the forefront of healthcare transformation, helping to shape how we support families in our community whilst advancing your own career in this exciting and rapidly evolving field.

Location & Travel Requirements

While based at Easingwold Health Centre, you'll be required to travel flexibly across all seven of our GP practices (Pickering, Kirkbymoorside, Helmsley, Terrington, Stillington, Tollerton, and Millfield) to deliver services and support patients in their local communities. This role therefore requires a current full driving licence and sole use of your own vehicle.

Person Specification

Qualifications

Essential

• - NVQ Level 3 in adult care (advanced level) or equivalent qualifications, or demonstrable commitment to working towards these
• - Demonstrable commitment to professional and personal development, enrolled in, undertaking or qualified from appropriate training as set out in the Personalised Care Institute core curriculum

Desirable

• - Additional healthcare, social care or related qualifications
• - Training in motivational interviewing, coaching techniques or behaviour change approaches
• - Completed safeguarding training relevant to children and vulnerable adults

Experience

Essential

• - Experience of working in health, social care and other support roles in direct contact with people, families or carers (in paid or voluntary capacity)
• - Experience of supporting people, their families and carers in a related role
• - Experience of working with vulnerable people, complying with best practice and relevant legislation
• - Proficiency in MS Office and web-based services

Desirable

• - Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health/health improvement
• - Experience of working within multi professional team environments
• - Experience or training in personalised care and support planning
• - Experience of data collection and using tools to measure the impact of services

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

South Hambleton and Ryedale Primary Care Network

Address

Easingwold Health Centre

Crabmill Lane

Easingwold

YO61 3BU

Employer's website

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