Job summary
Care co-ordinators help to co-ordinate and navigate care across the
health and care system, helping people make the right connections, with the
right teams at the right time. They can support people to become more active in
their own health and care and are skilled in assessing peoples changing needs.
Care co-ordinators are effective in bringing together multidisciplinary teams
to support peoples complex health and care needs.
They can be an effective intervention in supporting people to stay well
particularly those with long term conditions, multiple long-term conditions,
and people living with or at risk of frailty.
Care Coordinators provide the extra time, capacity and expertise to support
patients preparing for, or in following-up clinical conversations they have
with primary care professionals.
They will work closely with the GPs and other primary care professionals
within the PCN to identify and manage a caseload of identified patients,
including patients in the local care homes. The aim of the Care Coordinator is
to make sure that appropriate healthcare and support is made available to
patients and their carers to ensures that changing needs and requirements are
addressed in a timely
The post available will be 34 hours per week with working patterns to be discussed at interview. The rate of pay is £13.31 per hour, depending on experience with the option of an NHS or NEST pension.
Interviews will be taking place week commencing 17th June 2024.
Main duties of the job
This role is a new role being developed to focus
specifically on the needs of our elderly and frail patients and their families,
to provide support at a time which is most difficult and challenging for any
family. Working closely with our
Clinical Team, you will support patients by providing appropriate advice about
services available, review and discuss with the patient and their family their plans
for the future, liaise with external teams such as Hospice and Complex Care as
needed, and support our weekly care huddles.
Understanding the particular challenges for elderly and frail patients
and their family and services within the NHS would be an advantage.
The successful candidate will be kind, reflective
and self-aware and will enjoy working with a wide range of people. They will
have good communication and negotiation skills and a firm belief that people
have untapped resources within them, that can be unleashed by providing high
quality, non-judgemental support. They will be proactive with a flexible
attitude, keen to work as part of a team and committed to developing themselves
in this skilled role and supporting colleagues to do the same.
Care Co-ordinatorsare a key part of the Primary Care Network (PCN) multidisciplinary team, but based at Bruton Surgery working within a small team focused on improving the quality of life for our patients and working with our Clinical Team to support their medical needs.
About us
Symphony Healthcare Services Ltd. is a growing primary care organisation based in Somerset which aims to improve and develop the best patient-centred care and services in the country, and we are embracing change within general practice by implementing new and innovative models of care. If you are passionate about delivering outstanding healthcare and share our values, join us to support the achievement of our goals.
Job description
Job responsibilities
Key Responsibilities
- Provide one-to-one and group health coaching support for people with one or more long-term conditions, with the aim of: improving people’s levels of ‘activation’, empowering people to manage their own health and improve their health outcomes.
- Manage and prioritise a caseload, in accordance with the needs, priorities and support required by individuals in the caseload.
- Work as part of a multidisciplinary multi-agency team to promote health coaching and to be ambassadors for Personalised Care and Supported Self- Management, modelling the coaching approach in their work.
- Ensure that GPs, practice nurses, practice pharmacists and other members of the primary care team understand the health coach role, how to refer to them, and which patients may particularly benefit from health coaching.
- Support local health, social care and voluntary sector professionals to make appropriate referrals to the service.
- Promote and raise awareness of the health coaching service particularly to groups and communities that experience barriers to access.
- Attend and contribute to team, practice, and PCN meetings and events as required by the service.
- Work flexibly, adapting to the needs of the service and client group while maintaining the integrity of the role.
- Participate in regular health coaching supervision and continual learning.
- (Dependant on skills and ability) Contribute to and take part in health coaching train-the-trainer workshops in order to spread health coaching skills to support a mind-set shift among staff in how they have conversations, integrating a health coaching approach into how they work with people and each other, and to strengthen a shift towards an enabling a compassionate and coaching culture in their organisation.
- Collect service user experience and impact of health coaching as part of the delivery of personalised care. Participate and collect information that measures the impact of health coaching as an intervention that supports embedding personalised care into local health systems e.g. collect data entry relating to the health coaching activity in GP, Local Authority, and hospital clinical systems or other systems, as required.]
- Additionally, Health and Wellbeing Coaches may also want to consider evaluating people’s levels of knowledge, skills and confidence (their ‘Activation level’), using tools such as the Patient Activation Measurement (PAM). Focus on those with low levels of activation while recognising that people at other levels of activation may also benefit from health coaching. Measure the impact of the coaching provided on people’s activation level and adjust activity in response, to create a continuous improvement approach.
Key Tasks
- Provide personalised support
- Meet people on one-to-one or group consultation basis, by phone, video conference, or face-to-face.
- Give people time to tell their stories and focus on ‘what matters to me’;
- Build trust and respect with the person, providing non-judgemental and non- discriminatory support, respecting diversity and lifestyle choices;
- Work from a strength-based approach focusing on a person’s assets;
- Use a structured framework/model approach to coach individuals across a series of session to: identify what’s important to them; set personal goals and appropriate steps; build skills and confidence to achieve goals; and use problem-solving to work through challenges;
- Promote health coaching, its role in self-management as a part of personalised care, in addressing health inequalities and the wider determinants of health;
- As part of the PCN multidisciplinary team, build relationships with staff in GP practices within the local PCN, attending relevant MDT meetings, giving information and feedback on health coaching;
- Be proactive in developing strong links with all local organisations to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals;
- Work in partnership with local agencies to raise awareness of health coaching and how improving people’s knowledge, confidence and skills (patient activation) can enable them to improve their ability to manage their long-term conditions and reduce reliance on clinical services;
- Provide referral organisations with regular updates about health coaching, including information on how to encourage appropriate referrals;
- Seek regular feedback about the quality of service and impact of health coaching on referral agencies.
General Tasks
- Work sensitively with people, their families and carers to gather key information, enabling tracking of the impact of health and wellbeing coaching on their health and wellbeing;
- Encourage people, their families and carers to provide feedback and to share their stories about the impact of health coaching on their lives;
- Support referral organisations to provide appropriate information about the person they are referring. Provide appropriate feedback to referral agencies about the people they referred;
- Work closely within the MDT and with GP practices within the PCN to ensure that the relevant SNOMED codes to record activity are inputted into clinical systems (as outlined in the Network Contract DES), adhering to data protection legislation and data sharing agreements.
- Establish strong working relationships with GPs and practice teams and work collaboratively with other Health and Wellbeing Coaches, Care Coordinators and Social Prescribing Link Workers, supporting each other, respecting each other’s views and meeting regularly as a team;
- Act as a champion for health coaching as a part of the PCN’s personalised care offer for patients and organisations
- Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner;
- Identify opportunities and gaps in the service - and review risks and issues that could impact on service delivery - and provide feedback to continually improve the service and contribute to business planning;
- Contribute to the development of policies and plans relating to equality, diversity and health inequalities;
- Work in accordance with the practices’ and PCN’s policies and procedures;
- Contribute to the wider aims and objectives of the PCN to improve and support primary care.
Job description
Job responsibilities
Key Responsibilities
- Provide one-to-one and group health coaching support for people with one or more long-term conditions, with the aim of: improving people’s levels of ‘activation’, empowering people to manage their own health and improve their health outcomes.
- Manage and prioritise a caseload, in accordance with the needs, priorities and support required by individuals in the caseload.
- Work as part of a multidisciplinary multi-agency team to promote health coaching and to be ambassadors for Personalised Care and Supported Self- Management, modelling the coaching approach in their work.
- Ensure that GPs, practice nurses, practice pharmacists and other members of the primary care team understand the health coach role, how to refer to them, and which patients may particularly benefit from health coaching.
- Support local health, social care and voluntary sector professionals to make appropriate referrals to the service.
- Promote and raise awareness of the health coaching service particularly to groups and communities that experience barriers to access.
- Attend and contribute to team, practice, and PCN meetings and events as required by the service.
- Work flexibly, adapting to the needs of the service and client group while maintaining the integrity of the role.
- Participate in regular health coaching supervision and continual learning.
- (Dependant on skills and ability) Contribute to and take part in health coaching train-the-trainer workshops in order to spread health coaching skills to support a mind-set shift among staff in how they have conversations, integrating a health coaching approach into how they work with people and each other, and to strengthen a shift towards an enabling a compassionate and coaching culture in their organisation.
- Collect service user experience and impact of health coaching as part of the delivery of personalised care. Participate and collect information that measures the impact of health coaching as an intervention that supports embedding personalised care into local health systems e.g. collect data entry relating to the health coaching activity in GP, Local Authority, and hospital clinical systems or other systems, as required.]
- Additionally, Health and Wellbeing Coaches may also want to consider evaluating people’s levels of knowledge, skills and confidence (their ‘Activation level’), using tools such as the Patient Activation Measurement (PAM). Focus on those with low levels of activation while recognising that people at other levels of activation may also benefit from health coaching. Measure the impact of the coaching provided on people’s activation level and adjust activity in response, to create a continuous improvement approach.
Key Tasks
- Provide personalised support
- Meet people on one-to-one or group consultation basis, by phone, video conference, or face-to-face.
- Give people time to tell their stories and focus on ‘what matters to me’;
- Build trust and respect with the person, providing non-judgemental and non- discriminatory support, respecting diversity and lifestyle choices;
- Work from a strength-based approach focusing on a person’s assets;
- Use a structured framework/model approach to coach individuals across a series of session to: identify what’s important to them; set personal goals and appropriate steps; build skills and confidence to achieve goals; and use problem-solving to work through challenges;
- Promote health coaching, its role in self-management as a part of personalised care, in addressing health inequalities and the wider determinants of health;
- As part of the PCN multidisciplinary team, build relationships with staff in GP practices within the local PCN, attending relevant MDT meetings, giving information and feedback on health coaching;
- Be proactive in developing strong links with all local organisations to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals;
- Work in partnership with local agencies to raise awareness of health coaching and how improving people’s knowledge, confidence and skills (patient activation) can enable them to improve their ability to manage their long-term conditions and reduce reliance on clinical services;
- Provide referral organisations with regular updates about health coaching, including information on how to encourage appropriate referrals;
- Seek regular feedback about the quality of service and impact of health coaching on referral agencies.
General Tasks
- Work sensitively with people, their families and carers to gather key information, enabling tracking of the impact of health and wellbeing coaching on their health and wellbeing;
- Encourage people, their families and carers to provide feedback and to share their stories about the impact of health coaching on their lives;
- Support referral organisations to provide appropriate information about the person they are referring. Provide appropriate feedback to referral agencies about the people they referred;
- Work closely within the MDT and with GP practices within the PCN to ensure that the relevant SNOMED codes to record activity are inputted into clinical systems (as outlined in the Network Contract DES), adhering to data protection legislation and data sharing agreements.
- Establish strong working relationships with GPs and practice teams and work collaboratively with other Health and Wellbeing Coaches, Care Coordinators and Social Prescribing Link Workers, supporting each other, respecting each other’s views and meeting regularly as a team;
- Act as a champion for health coaching as a part of the PCN’s personalised care offer for patients and organisations
- Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner;
- Identify opportunities and gaps in the service - and review risks and issues that could impact on service delivery - and provide feedback to continually improve the service and contribute to business planning;
- Contribute to the development of policies and plans relating to equality, diversity and health inequalities;
- Work in accordance with the practices’ and PCN’s policies and procedures;
- Contribute to the wider aims and objectives of the PCN to improve and support primary care.
Person Specification
Knowledge and Skills
Essential
- Essential
- Proven record of excellent written and verbal communication skills and
- interpersonal skills
- Excellent organisational and admin skills
- Analytical skills and ability to interpret information and present it in a clear and concise manner
- Evidence of excellent knowledge and competence with Microsoft Office
- Able to deal with service users sensitively
- Able to work effectively as part of a team
- Able to prioritise and manage own workload with minimal supervision
- Willingness to undergo further training and committed to own development
- Car user as travel between sites across the area will be required Desirable
- Experience providing advice/signposting to users
- Excellent motivational and influencing skills
Desirable
- Experience providing advice/signposting to users
- Excellent motivational and influencing skills
Experience
Essential
- Experience of using coaching approaches/frameworks and models or other helping strategies e.g. Motivational Interviewing
- An understanding of the biopsychosocial model of health and the social determinants of health
- Experience of working within a team
Desirable
- Experience of working in the NHS or similar health care setting
- Awareness of clinical systems such as EMIS
- Networking experience
- Experience of working in a multidisciplinary team
- Experience of working in health and social care care/community development setting or similar
Qualifications
Essential
- NVQ Level 2 or equivalent
- Willing to work towards NVQ Level 3
Desirable
Person Specification
Knowledge and Skills
Essential
- Essential
- Proven record of excellent written and verbal communication skills and
- interpersonal skills
- Excellent organisational and admin skills
- Analytical skills and ability to interpret information and present it in a clear and concise manner
- Evidence of excellent knowledge and competence with Microsoft Office
- Able to deal with service users sensitively
- Able to work effectively as part of a team
- Able to prioritise and manage own workload with minimal supervision
- Willingness to undergo further training and committed to own development
- Car user as travel between sites across the area will be required Desirable
- Experience providing advice/signposting to users
- Excellent motivational and influencing skills
Desirable
- Experience providing advice/signposting to users
- Excellent motivational and influencing skills
Experience
Essential
- Experience of using coaching approaches/frameworks and models or other helping strategies e.g. Motivational Interviewing
- An understanding of the biopsychosocial model of health and the social determinants of health
- Experience of working within a team
Desirable
- Experience of working in the NHS or similar health care setting
- Awareness of clinical systems such as EMIS
- Networking experience
- Experience of working in a multidisciplinary team
- Experience of working in health and social care care/community development setting or similar
Qualifications
Essential
- NVQ Level 2 or equivalent
- Willing to work towards NVQ Level 3
Desirable
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.
