Job summary
Care co-ordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide
co-ordination and navigation of care and support across health and care services.
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 people 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 co-ordinators could provide time, capacity and expertise to support people in preparing for, or following-up, clinical conversations. Enabling them to be more actively involved in managing their care and supporting them to make choices that are right for them. Care co-ordinators help people improve their quality of life.
Main duties of the job
We are seeking a highly motivated individual willing to work collaboratively across the PCN to support practices and linked care homes.
About us
South Norfolk Healthcare is a GP Provider Organisation supporting 23 GP organisations in South Norfolk:
We are recruiting this role on behalf of Ketts Oak Primary Care Network, the role will be hosted by Hingham Surgery. Kett's Oak PCN consists of the following GP organisations:
- East Harling and Kenninghall
- Wymondham Medical Practice
- Humbleyard Practice
- Windmill Surgery
- Hingham Surgery
Job description
Job responsibilities
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.
There may be a need to work remotely depending on the requirements of the role.
Please note that the care co-ordinator works under delegation of a registered health professional.
Work with people, their families and carers, to improve their understanding of their condition.
Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.
Provide co-ordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.
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 back to other health professionals within the PCN.
Support the co-ordination 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 people to be more prepared to have shared decision-making conversations.
Explore and assist people to access a personal health budget where appropriate.
Work with commissioners, integrated locality teams and other agencies to support and further develop the role.
Key Tasks
- Enable access to personalised care and support
- Take referrals or proactively identify people who could benefit from support through care co-ordination.
- Have a positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
- Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance.
- 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.
- Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.
- Support people to develop and implement personalised care and support plans.
- Review and update personalised care and support plans at regular intervals.
- 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, with activity recorded using the relevant SNOMED codes.
- Where a personal health budget is an option, work with the person and the local ICS team to provide advice and support as appropriate.
- Co-ordinate and integrate care
- Make and manage appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
- Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system.
- Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.
- Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a co-ordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
- Actively participate in multidisciplinary team meetings in the PCN.
- Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
- Record what interventions are used to support people, and how people are developing on their health and care journey.
- Data and information capture:
- Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
- Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care co-ordination on their health and wellbeing.
- Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives.
- Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
- Supervision/ professional development
- Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required.
- Adhere to organizational policies and procedures including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
- Access relevant GPs to discuss patient related concerns, and be supported to follow appropriate safeguarding procedures
- Access regular supervision.
Job description
Job responsibilities
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.
There may be a need to work remotely depending on the requirements of the role.
Please note that the care co-ordinator works under delegation of a registered health professional.
Work with people, their families and carers, to improve their understanding of their condition.
Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.
Provide co-ordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.
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 back to other health professionals within the PCN.
Support the co-ordination 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 people to be more prepared to have shared decision-making conversations.
Explore and assist people to access a personal health budget where appropriate.
Work with commissioners, integrated locality teams and other agencies to support and further develop the role.
Key Tasks
- Enable access to personalised care and support
- Take referrals or proactively identify people who could benefit from support through care co-ordination.
- Have a positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
- Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance.
- 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.
- Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly.
- Support people to develop and implement personalised care and support plans.
- Review and update personalised care and support plans at regular intervals.
- 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, with activity recorded using the relevant SNOMED codes.
- Where a personal health budget is an option, work with the person and the local ICS team to provide advice and support as appropriate.
- Co-ordinate and integrate care
- Make and manage appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
- Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system.
- Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.
- Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a co-ordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
- Actively participate in multidisciplinary team meetings in the PCN.
- Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
- Record what interventions are used to support people, and how people are developing on their health and care journey.
- Data and information capture:
- Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
- Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care co-ordination on their health and wellbeing.
- Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives.
- Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
- Supervision/ professional development
- Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required.
- Adhere to organizational policies and procedures including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
- Access relevant GPs to discuss patient related concerns, and be supported to follow appropriate safeguarding procedures
- Access regular supervision.
Person Specification
Experience
Essential
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity) Experience of working within multi - professional team environments Experience of supporting people, their families and carers in a related role Experience of data collection and using tools to measure the impact of services.
Desirable
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity) Experience of working within multi - professional team environments Experience of supporting people, their families and carers in a related role Experience of data collection and using tools to measure the impact of services.
Skills & Knowledge
Essential
- Understanding of personalised care and the comprehensive model of personalised care Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers Understanding of, and commitment to, equality, diversity and inclusion Strong organisational skills, including planning, prioritising, time management and record keeping Knowledge of how the NHS works, including primary care and PCNs Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social.
Desirable
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes. Ability to recognise and work within limits of competence and seek advice when needed.
Qualifications
Desirable
- A-level / NVQ 3 or equivalent experience in admin / customer service environment
Person Specification
Experience
Essential
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity) Experience of working within multi - professional team environments Experience of supporting people, their families and carers in a related role Experience of data collection and using tools to measure the impact of services.
Desirable
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity) Experience of working within multi - professional team environments Experience of supporting people, their families and carers in a related role Experience of data collection and using tools to measure the impact of services.
Skills & Knowledge
Essential
- Understanding of personalised care and the comprehensive model of personalised care Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers Understanding of, and commitment to, equality, diversity and inclusion Strong organisational skills, including planning, prioritising, time management and record keeping Knowledge of how the NHS works, including primary care and PCNs Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social.
Desirable
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes. Ability to recognise and work within limits of competence and seek advice when needed.
Qualifications
Desirable
- A-level / NVQ 3 or equivalent experience in admin / customer service environment
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.
