Job summary
You will be responsible for co-ordinating, integrating and delivering support to practice patients with identified mental health needs. You will ensure patients have good quality information to help them make informed choices about their care by liaising with a broad range of medical social and third sector services. You will ensure effective and synchronized care is available to these patients, proactively identifying their personalised care needs, using the available decision support aids. You will bring together the patients identified care and support needs and explore with them, their options to meet these into a single personalised care and support plan (PCSP).
You will work with patients, their families and carers, to improve their health and wellbeing by navigating them to the appropriate services. Ensure they have good quality information to support their decision making, by taking a holistic approach, bringing together all of their identified care and support requirements into a single personalised plan based on what matters most to the patient. This could include access to self-management education courses, peer support or interventions that assist them in their health and wellbeing as well as supporting patients to take up training and employment.
You will guide them to access these services and any appropriate funding that is available to support them, including access personal health budgets where appropriate.
Main duties of the job
Service Delivery:
Build and develop a robust knowledge of health, social and third sector provision in the Sedgefield area.
Build and develop strong working relationships with health, social and third sector providers in the Sedgefield 1 PCN area, including GP practices.
Work closely with professionals from a variety of health specialties.
Prepare proactive care plans for vulnerable patients.
Build relationships with patients, their families and carers. Carry out regular visits, telephone consultations and reviews within the community setting and at dedicated venues.
Be the patients advocate to the health and social care system.
Signpost patients to appropriate services and sources of funding and where appropriate assist in accessing such funding.
Communication:
Attend practice level MDT meetings to discuss patients and coordinate with other care providers.
Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed.
Communicate with and support patients who are receiving bad news.
Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating.
Anticipate barriers to communication and take action to overcome this.
Maintain effective communication within the practice environment and with external stakeholders.
About us
Sedgefield 1 Primary Care Network (PCN) is an innovative and dynamic group combining 4 local GP Practices based in the Newton Aycliffe and Shildon locality, with a population of over 41,000 patients. We are continually seeking new ways to support and improve local healthcare services to our patient population.
We are looking to appoint a Care Coordinator to focus on mental health issues to work within the Primary Care Network joining our growing multi-disciplinary team which includes Social Prescribing Link Workers, Clinical Pharmacists, First Contact Physiotherapists and Primary Mental Health Nurses. You will be part of Sedgefield 1 PCN and be based at Jubilee Medical Practice.
We are committed to the ongoing development of our team, which includes mandatory and developmental training for all our staff. Team members are encouraged to highlight any training they feel would benefit them in the achievement of their role.
Job description
Job responsibilities
You will be responsible for co-ordinating, integrating and delivering support to practice patients with identified mental health needs. You will ensure patients have good quality information to help them make informed choices about their care by liaising with a broad range of medical social and third sector services. You will ensure effective and synchronized care is available to these patients, proactively identifying their personalised care needs, using the available decision support aids. You will bring together the patients identified care and support needs and explore with them, their options to meet these into a single personalised care and support plan (PCSP).
You will work with patients, their families and carers, to improve their health and wellbeing by navigating them to the appropriate services. Ensure they have good quality information to support their decision making, by taking a holistic approach, bringing together all of their identified care and support requirements into a single personalised plan based on what matters most to the patient. This could include access to self-management education courses, peer support or interventions that assist them in their health and wellbeing as well as supporting patients to take up training and employment.
You will guide them to access these services and any appropriate funding that is available to support them, including access personal health budgets where appropriate.
By using Population Health Intelligence, the service may be targeted at specific patient groups, identified by the GP practice. These patients will include but are not limited to adults with complex long term health needs, depression, organic mental illness, and those who are at risk of social isolation. You will be responsible to act on the follow up requirements contained in Secondary Care discharge letters, ensuring patients are aware of any additional monitoring or tests that are required and the timescales.
You will liaise with secondary care clinics, supporting their requests for pre-assessments conducted in primary care, this will include engaging with the patient, organising appropriate appointments (within practice clinics or in their own homes), undertaking in depth one-to-one structured interviews and then ensuring the results are returned to the requesting clinician/service.
You may be required to perform minor clinical observations such as basic monitoring, recording of vital signs or blood pressure monitoring on behalf of the Primary Care Networks and GP practice. These requirements may need to be carried out in the community or the practice. Appropriate training and support will be provided as required.
You may work in a variety of venues in the community, including patients homes, utilising premises in agreement with stakeholders and clients, as well as the base GP practice.
You will work collaboratively with the general practice team, including social prescribing link workers, and the primary care mental health team to meet the needs of patients and to support the delivery of the Primary Care Network responsibilities and objectives.
Please see the attached Job Description in Supporting Documents for more information.
Job description
Job responsibilities
You will be responsible for co-ordinating, integrating and delivering support to practice patients with identified mental health needs. You will ensure patients have good quality information to help them make informed choices about their care by liaising with a broad range of medical social and third sector services. You will ensure effective and synchronized care is available to these patients, proactively identifying their personalised care needs, using the available decision support aids. You will bring together the patients identified care and support needs and explore with them, their options to meet these into a single personalised care and support plan (PCSP).
You will work with patients, their families and carers, to improve their health and wellbeing by navigating them to the appropriate services. Ensure they have good quality information to support their decision making, by taking a holistic approach, bringing together all of their identified care and support requirements into a single personalised plan based on what matters most to the patient. This could include access to self-management education courses, peer support or interventions that assist them in their health and wellbeing as well as supporting patients to take up training and employment.
You will guide them to access these services and any appropriate funding that is available to support them, including access personal health budgets where appropriate.
By using Population Health Intelligence, the service may be targeted at specific patient groups, identified by the GP practice. These patients will include but are not limited to adults with complex long term health needs, depression, organic mental illness, and those who are at risk of social isolation. You will be responsible to act on the follow up requirements contained in Secondary Care discharge letters, ensuring patients are aware of any additional monitoring or tests that are required and the timescales.
You will liaise with secondary care clinics, supporting their requests for pre-assessments conducted in primary care, this will include engaging with the patient, organising appropriate appointments (within practice clinics or in their own homes), undertaking in depth one-to-one structured interviews and then ensuring the results are returned to the requesting clinician/service.
You may be required to perform minor clinical observations such as basic monitoring, recording of vital signs or blood pressure monitoring on behalf of the Primary Care Networks and GP practice. These requirements may need to be carried out in the community or the practice. Appropriate training and support will be provided as required.
You may work in a variety of venues in the community, including patients homes, utilising premises in agreement with stakeholders and clients, as well as the base GP practice.
You will work collaboratively with the general practice team, including social prescribing link workers, and the primary care mental health team to meet the needs of patients and to support the delivery of the Primary Care Network responsibilities and objectives.
Please see the attached Job Description in Supporting Documents for more information.
Person Specification
Qualifications
Essential
- GCSE Grade C or above in Maths and English, or equivalent.
Desirable
- Qualification in a health or social care allied profession.
- Counselling qualification.
Experience
Desirable
- Experience of working with people with mental health needs.
- Experience of assisting Mental Health Professionals.
- Experience of structured interviewing.
- Experience of working with or caring for elderly people, friends or relations.
- Experience of working in social care of health.
Person Specification
Qualifications
Essential
- GCSE Grade C or above in Maths and English, or equivalent.
Desirable
- Qualification in a health or social care allied profession.
- Counselling qualification.
Experience
Desirable
- Experience of working with people with mental health needs.
- Experience of assisting Mental Health Professionals.
- Experience of structured interviewing.
- Experience of working with or caring for elderly people, friends or relations.
- Experience of working in social care of health.
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.
