Job summary
The EHCH Care Coordinator plays a pivotal role in improving the quality and coordination of health and care services for residents in care homes. Working within a multidisciplinary team across the Primary Care Network (PCN), the post-holder will support the delivery of the Enhanced Health in Care Homes Framework. This includes facilitating proactive, personalised care, improving communication between care homes and healthcare providers, and ensuring residents receive timely and appropriate care.
Main duties of the job
The Care
Coordinator's role will support the PCN leadership team and GPs in coordinating
all key activity including improving access to services, providing advice and
information, and ensuring health and care planning is timely, efficient, and
patient-centred. The role will include supporting digital initiatives and
includes responsibilities for the co-ordination of the patients journey
through primary care.
The successful
candidate will have excellent and proven negotiation and communication skills and will have an
understanding of primary care services & community health services.
About us
Meridian Medical Primary Care Network (PCN) is a collaborative network of four local GP practices serving the Louth, Woodhall Spa, Tetford, North Somercotes, and Manby areas in Lincolnshire, UK.
Meridian Medical PCN comprises the following GP practices: James Street Family Practice (Louth), Tasburgh Lodge Surgery (Woodhall Spa),East Lindsey Medical Group (Louth/Tetford),Marsh Medical Practice (North Somercotes)
Together, these practices serve an adjusted patient population of approximately 43,000 people.
The PCN includes care homes that can accommodate over 600 residents, spanning small to larger units, including those specialising in dementia care and complex health needs. A designated Care Coordinator role works with the PCN leadership and local multi-disciplinary teams to support residents in care homes, facilitating timely, patient-centered care, and acting as a liaison with families, staff, and healthcare professionals
Lincolnshire & District Medical Services (LADMS) Ltd is a federation of GPs delivering primary medical services in Lincolnshire, predominantly in the East of the county. Our main contracts include GP Extended Access services, the Covid-19 vaccination programme and the provision of INR services along the East coast.
Close working relationships exist between the PCN and LADMS.
Job description
Job responsibilities
KEY RESPONSIBILITIES:
Working with patients:
- Work with individual patients, their families and carers, using a holistic approach, to identify their goals for care, and agree a personalised care and support plan for their care.
- Support delivery of those care plans by coordinating input from a range of different professionals and services, and helping patients and their carers/family to navigate across health and social care services.
- Work as part of the primary care team, coordinating care between GPs, Practice Nurses, Clinical Pharmacists, Social Prescribing Link Worker and Health and Wellbeing Coach.
- Help patients to manage their needs through answering queries, being a first point of contact in the practice, and by making and managing appointments.
- Support patients to utilise decision aids in preparation for a shared decision-making conversations and ensure that they, and their carers/family have access to good quality written and verbal information to help them male choices about their care.
- Support patients to take up training and employment where appropriate, and to access benefits where eligible.
- Help patients to access personal health budgets where appropriate.
- Make use of tools such as Patient Activation Measure when engaging with patients.
- Help patients to access self-management education courses, peer support or other interventions that support them in improving their health and well being.
- Undertake regular reviews of the personalised care and support plans developed with patients.
- Work in line with national best practice when developing personalised care and support plans.
- Work with patients over the phone, in person in the practice or, for those who are housebound, where necessary carry out home visits.
Administration:
- Use practice level reports to identify suitable cohorts of patients to deliver personalised care
- Provide accurate and timely data to support audit and monitoring of the service, and any data returns as required by the ICB
- Keep accurate and up to date records of contacts with patients and their carers/families in the patient's GP record and in their care plan
- Follow up documentation required for care planning from other organisations, making use of Local Care Record where useful
- Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations' communications and patients notes, and ensuring care packages are set up
- Collect data on patients/carers for recognised outcome measures and document for service interpretation
- Managing any necessary meetings to support care planning, identifying patients for discussion, organising the meeting and circulating required information beforehand as necessary
- Ensure that meeting actions are recorded, disseminated and followed up in a timely way.
As this is a new and evolving role,
this is not an exhaustive list of duties and responsibilities, and the post
holder may be required to undertake other duties that fall
within the grade of the job, in discussion with their line manager.
The content of this job description
will be reviewed regularly in the light of changing service
requirements and any such changes will be discussed with the post holder.
Job description
Job responsibilities
KEY RESPONSIBILITIES:
Working with patients:
- Work with individual patients, their families and carers, using a holistic approach, to identify their goals for care, and agree a personalised care and support plan for their care.
- Support delivery of those care plans by coordinating input from a range of different professionals and services, and helping patients and their carers/family to navigate across health and social care services.
- Work as part of the primary care team, coordinating care between GPs, Practice Nurses, Clinical Pharmacists, Social Prescribing Link Worker and Health and Wellbeing Coach.
- Help patients to manage their needs through answering queries, being a first point of contact in the practice, and by making and managing appointments.
- Support patients to utilise decision aids in preparation for a shared decision-making conversations and ensure that they, and their carers/family have access to good quality written and verbal information to help them male choices about their care.
- Support patients to take up training and employment where appropriate, and to access benefits where eligible.
- Help patients to access personal health budgets where appropriate.
- Make use of tools such as Patient Activation Measure when engaging with patients.
- Help patients to access self-management education courses, peer support or other interventions that support them in improving their health and well being.
- Undertake regular reviews of the personalised care and support plans developed with patients.
- Work in line with national best practice when developing personalised care and support plans.
- Work with patients over the phone, in person in the practice or, for those who are housebound, where necessary carry out home visits.
Administration:
- Use practice level reports to identify suitable cohorts of patients to deliver personalised care
- Provide accurate and timely data to support audit and monitoring of the service, and any data returns as required by the ICB
- Keep accurate and up to date records of contacts with patients and their carers/families in the patient's GP record and in their care plan
- Follow up documentation required for care planning from other organisations, making use of Local Care Record where useful
- Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations' communications and patients notes, and ensuring care packages are set up
- Collect data on patients/carers for recognised outcome measures and document for service interpretation
- Managing any necessary meetings to support care planning, identifying patients for discussion, organising the meeting and circulating required information beforehand as necessary
- Ensure that meeting actions are recorded, disseminated and followed up in a timely way.
As this is a new and evolving role,
this is not an exhaustive list of duties and responsibilities, and the post
holder may be required to undertake other duties that fall
within the grade of the job, in discussion with their line manager.
The content of this job description
will be reviewed regularly in the light of changing service
requirements and any such changes will be discussed with the post holder.
Person Specification
Qualifications
Essential
- Core level of Maths and English
- Relationship building skills
- Empathy and patience
Desirable
- Qualifications in Health & Social Care and/or Customer Service
Experience
Essential
- An understanding/experience of healthcare or care home provision.
- Experience of preparing plans and reporting progress against these.
- Experience of analysing and interpreting information and present results in a clear and concise manner.
- Experience of administrative skills and robust record-keeping.
Desirable
- Experience of using SystmOne clinical system.
- Understanding of wider healthcare delivery including roles of core MDT members and role of primary care.
- Experience of providing advice/signposting to patients.
- Experience of co-ordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
- Experience of organising recurrent events.
- Understanding/experience of using tools to create individualised plans.
- Awareness of digital solutions to support independent living/remote healthcare monitoring.
Skills and Knowledge
Essential
- Demonstrate and understanding of the Primary Care Network.
- Awareness of clinical governance issues in primary care.
- Ability to present plans, outcomes and learning to stakeholders.
- Demonstrate commitment to professional and personal development.
- Communication skills, both written and verbal.
- Understanding of, and commitment to, equality, diversity and inclusion.
Desirable
- Demonstrate ability to improve quality within the limitations of the service.
Personal Attributes
Essential
- Ability to work independently as well as collaboratively in a team.
- Ability to work without direct supervision.
- Committed to personal and team development.
- Committed to person-centred, non-discriminatory practice.
- Aware of requirements of confidentiality.
- Forward thinking.
- Excellent interpersonal skills and a confident approach.
- Professional, approachable and respectful attitude towards others.
- Able to maintain judgement under pressure.
- Able to maintain motivations, drive and enthusiasm.
- Flexible approach to work.
- Ability to travel around the PCN patch if required to fulfil the role.
Desirable
- An ability to provide constructive feedback in a professional manner.
- Recognises the role of other colleagues and their role to patient care.
- Ability to recognise personal limitations and refer to more appropriate colleagues when necessary.
Person Specification
Qualifications
Essential
- Core level of Maths and English
- Relationship building skills
- Empathy and patience
Desirable
- Qualifications in Health & Social Care and/or Customer Service
Experience
Essential
- An understanding/experience of healthcare or care home provision.
- Experience of preparing plans and reporting progress against these.
- Experience of analysing and interpreting information and present results in a clear and concise manner.
- Experience of administrative skills and robust record-keeping.
Desirable
- Experience of using SystmOne clinical system.
- Understanding of wider healthcare delivery including roles of core MDT members and role of primary care.
- Experience of providing advice/signposting to patients.
- Experience of co-ordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
- Experience of organising recurrent events.
- Understanding/experience of using tools to create individualised plans.
- Awareness of digital solutions to support independent living/remote healthcare monitoring.
Skills and Knowledge
Essential
- Demonstrate and understanding of the Primary Care Network.
- Awareness of clinical governance issues in primary care.
- Ability to present plans, outcomes and learning to stakeholders.
- Demonstrate commitment to professional and personal development.
- Communication skills, both written and verbal.
- Understanding of, and commitment to, equality, diversity and inclusion.
Desirable
- Demonstrate ability to improve quality within the limitations of the service.
Personal Attributes
Essential
- Ability to work independently as well as collaboratively in a team.
- Ability to work without direct supervision.
- Committed to personal and team development.
- Committed to person-centred, non-discriminatory practice.
- Aware of requirements of confidentiality.
- Forward thinking.
- Excellent interpersonal skills and a confident approach.
- Professional, approachable and respectful attitude towards others.
- Able to maintain judgement under pressure.
- Able to maintain motivations, drive and enthusiasm.
- Flexible approach to work.
- Ability to travel around the PCN patch if required to fulfil the role.
Desirable
- An ability to provide constructive feedback in a professional manner.
- Recognises the role of other colleagues and their role to patient care.
- Ability to recognise personal limitations and refer to more appropriate colleagues when necessary.
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
Lincolnshire And District Medical Services (LADMS)
Address
Office 7
Fairfield Enterprise Centre
Fairfield Industrial Estate
Louth, Lincolnshire
LN11 0LS
Employer's website
http://www.ladms.co.uk/ (Opens in a new tab)
