Care Coordinator - Age Well

Job description

Job responsibilities

About the Role

This Care Co-ordinator position within our 'Age Well' service represents an exciting opportunity to join SHaR PCN's innovative approach to supporting older people. You'll be working at the forefront of preventative healthcare, helping older people 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 'Age Well' work stream, which addresses the health and wellbeing needs of people over 65, working proactively with robust data analysis to optimise health outcomes through early intervention and holistic support.

The Age Well Approach

The 'Age Well' service focuses on prevention and early intervention to improve the health and wellbeing of older people. Your role will support the ongoing identification, engagement and case management of older people based on data-driven approaches and holistic health and care support. You'll ensure older people can access services and receive appropriate support when they need it, helping them maintain independence and quality of life in their own communities.

Key Responsibilities

Proactive Identification and Engagement Using population health intelligence and robust data analysis, you'll proactively identify older people who could benefit from care co-ordination support. This includes people who are frail, living with long-term health conditions including cancer, or at risk of health decline. You'll take referrals from health professionals and work to engage people early, before crises occur.

First Contact and Relationship Building You'll serve as the first point of contact for older people entering our Age Well pathway. This involves establishing trusted, supportive relationships with each person and their family or carers. Your empathetic approach and excellent communication skills will be essential in creating an environment where older people feel comfortable discussing their needs, concerns and what matters most to them about maintaining their independence and wellbeing.

Holistic Assessment You'll conduct comprehensive, holistic assessments that go beyond medical needs to understand the person's full situation. This involves exploring wider determinants of health such as housing conditions, financial concerns, social isolation, caring responsibilities, and how these impact on their health and wellbeing. You'll work with the person, their families and carers to understand their priorities and aspirations.

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. These plans will be based on what matters most to the person, focusing on maintaining independence, preventing deterioration and supporting people to live well. Plans will be regularly reviewed and updated to reflect changing needs and progress.

Supporting Independence You'll work with individuals to help them maintain or regain independence through various approaches including living skills support, signposting to adaptations and equipment, enablement approaches and simple safeguards. Your strength-based approach will focus on what people can do for themselves whilst ensuring appropriate support is in place where needed.

Care Co-ordination Across Sectors You'll work closely with multiple professionals across different sectors to co-ordinate support for older people and their families. This includes liaising with GPs, nursing staff, Occupational Therapists within the Personalised Care Team, social prescribing link workers, social care, voluntary sector organisations and other PCN colleagues. Your role as a conduit will ensure older people receive seamless, well-coordinated care that addresses their complex needs.

Ongoing Case Management You'll maintain ongoing relationships with older people through regular check-ins and follow-ups, helping them make progress towards their planned outcomes. This involves monitoring their wellbeing, identifying any deterioration or new concerns early, adapting care plans as needed, and ensuring people feel supported throughout their journey. You'll track whether people are receiving the support outlined in their plans and take action if there are delays or barriers.

Navigation and Information Provision Your role includes helping older people and their families navigate the often complex health and care system. You'll answer queries, make and manage appointments, and ensure 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, community resources and voluntary sector services to enable effective signposting and referrals.

Working with Frailty and Long-Term Conditions A significant focus of your work will be supporting people who are frail or living with long-term health conditions including cancer. You'll need to understand the complexities involved medical, physical, emotional and social and work sensitively with people at vulnerable times in their lives. You'll collaborate with clinical colleagues to ensure care plans address both clinical and non-clinical needs.

Professional Collaboration Working within our integrated neighbourhood team, you'll collaborate with diverse health and care professionals. This includes attending multidisciplinary team meetings, preparing reports for clinical leads, and ensuring effective information sharing whilst maintaining appropriate confidentiality. You'll work particularly closely with the Personalised Care Team Occupational Therapist who provides your line management and clinical supervision.

Service Development and Quality Improvement As part of implementing and developing the Age Well 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 about what works well for older people will be crucial in refining our approach.

Health Inequalities and Engagement You'll play a vital role in identifying health inequalities within our older population and providing feedback on how engagement could be enhanced. This is particularly important for reaching older people who may be isolated or whom statutory services find hard to reach. You'll work proactively to ensure equitable access to services for older people from all backgrounds and communities.

Record Keeping and Information Governance You'll maintain accurate, appropriately coded records in patients' notes, including details of services they are referred to and outcomes of interventions. You'll ensure personalised care and support plans are communicated to GPs and other professionals involved in each person's care and uploaded to relevant online care records. 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 requires the ability to visit people in their own homes where appropriate, within organisational policies and lone working procedures.

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, clinical supervision from the Personalised Care Team Occupational Therapist, and support from our PCN Clinical Lead.

Career Development and Learning

This position offers significant opportunities for professional development within the expanding field of personalised care co-ordination for older people. 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 focused on frailty, ageing well and preventative care. You'll be working at the forefront of healthcare transformation, helping to shape how we support older people in our community whilst advancing your own career in this exciting and rapidly evolving field.

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
• - Proficiency in MS Office and web-based services

Desirable

• - Healthcare, social care or gerontology-related qualifications
• - Training in motivational interviewing, coaching techniques or behaviour change approaches
• - Completed safeguarding training relevant to vulnerable adults
• - Training or qualification related to frailty, long-term conditions or end of life care

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

Desirable

• - Experience of working directly in a care co-ordinator role, adult health and social care, or with older people
• - Experience of working with older people who are frail or have long-term conditions
• - 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 service impact
• - Experience of supporting people to maintain independence through enablement approaches

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)