Job summary
MIAA Solutions are advertising the above role in behalf of Healthier South Wirral PCN.
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.
Please note interviews will take place on 11th August
Main duties of the job
The following are the core responsibilities of
the Care Co-ordinator
There may be, on occasion, a requirement to
carry out other tasks. This will be dependent upon factors such as workload and
staffing levels:
The following core responsibilities are
specific to the PCC role supporting the GPCP team:
To
coordinate care and support for patients on significant or complex medications.
To
act as first point of contact for queries as they come, looking out for trends
across the practices.
To
manage the team rota to ensuring each practice gets its fair share of allocated
time.
To
measure outcomes and monitor reports
To
manage timely comms between the GPCP team and the 6 PCN Practices.
To
keep abreast of what is going on locally/nationally (e.g. PQRS, DES, QOF).
Working
with the practices to understand their individual needs.
To
facilitate a HSW network for colleagues involved in medicines management,
developing learning opportunities and sharing best practice.
To
communicate with local pharmacies as required to support patients and
colleagues with medicines management issues.
To
work with the GPCP to create processes and procedures that streamline patient
pathways.
To
work with the GPCP and other services to create links and pathways for example
wellbeing practitioners, health coaches.
To
support patient education around medicines adherence.
About us
Healthier South Wirral Primary Care Network is a group of 6 GP practices in and around the South of Wirral.
The practices that form our Network are:
- Sunlight Group Practice
- Spital Surgery
- The Orchard Surgery
- The Allport Surgery
- Eastham Group Practice
- Civic Medical Centre
This role will specifically work within the GPCP Team and with patients on significant or complex medication regimes or others as deemed appropriate on behalf of all 6 member practices but may shift on to other projects as services develop.
Job description
Job responsibilities
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.
Support
people to develop and implement personalised care and support plans.
Review
and update personalised care and support plans at regular intervals.
Co-ordinate and integrate care
Make
and manage appointments for patients, related to primary, secondary, community,
local authority, statutory, and voluntary organisations.
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.
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 organisational 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.
Miscellaneous
Establish
strong working relationships with GPs and practice teams and work
collaboratively with other care co-ordinators, social prescribing link workers
and health and wellbeing coaches, supporting each other, respecting each
others views and meeting regularly as a team.
Act
as a champion for personalised care and shared decision making within the PCN.
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 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
reduction of health inequalities.
Work
in accordance with the practices and PCNs policies and procedures.
Contribute
to the wider aims and objectives of the PCN to improve and support primary
care.
Personalised Care Institute (PCI) training
The PCI was launched in September 2020. It is
a virtual organisation accountable for setting the standards for evidence based
training in personalised care in England.
Details of PCI accredited training for care
co-ordinators and organisations that provide the training can be found on the
PCI website.
On completion of training, learners will be
registered with the PCI and receive a completion certificate.
Job description
Job responsibilities
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.
Support
people to develop and implement personalised care and support plans.
Review
and update personalised care and support plans at regular intervals.
Co-ordinate and integrate care
Make
and manage appointments for patients, related to primary, secondary, community,
local authority, statutory, and voluntary organisations.
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.
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 organisational 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.
Miscellaneous
Establish
strong working relationships with GPs and practice teams and work
collaboratively with other care co-ordinators, social prescribing link workers
and health and wellbeing coaches, supporting each other, respecting each
others views and meeting regularly as a team.
Act
as a champion for personalised care and shared decision making within the PCN.
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 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
reduction of health inequalities.
Work
in accordance with the practices and PCNs policies and procedures.
Contribute
to the wider aims and objectives of the PCN to improve and support primary
care.
Personalised Care Institute (PCI) training
The PCI was launched in September 2020. It is
a virtual organisation accountable for setting the standards for evidence based
training in personalised care in England.
Details of PCI accredited training for care
co-ordinators and organisations that provide the training can be found on the
PCI website.
On completion of training, learners will be
registered with the PCI and receive a completion certificate.
Person Specification
Experience
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
- 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 how the NHS works, including primary care and PCNs
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes Ability to recognise and work within limits of competence and seek advice when needed
Personal Qualities
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
- Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from diverse communities
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders
- Ability to identify risk and assess / manage risk when working with individuals
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health
- professionals/agencies, when what the person needs is beyond the scope of the care co-ordinator role e.g. when there is a mental health need requiring a qualified practitioner
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- Ability to demonstrate personal accountability, emotional resilience and work well under pressure
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
- Demonstrable commitment to professional and personal development
- Completed a two day PCI accredited care co-ordination training course or be willing to complete one prior to taking referrals.
- Proficient in MS Office and web -based services
Desirable
- Ability to provide motivational coaching to support peoples behaviour change
Qualifications
Essential
- Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement
- 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 a Pharmacy setting
- Experience or training in personalised care and support planning
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
Person Specification
Experience
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
- 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 how the NHS works, including primary care and PCNs
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes Ability to recognise and work within limits of competence and seek advice when needed
Personal Qualities
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
- Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from diverse communities
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders
- Ability to identify risk and assess / manage risk when working with individuals
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health
- professionals/agencies, when what the person needs is beyond the scope of the care co-ordinator role e.g. when there is a mental health need requiring a qualified practitioner
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- Ability to demonstrate personal accountability, emotional resilience and work well under pressure
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
- Demonstrable commitment to professional and personal development
- Completed a two day PCI accredited care co-ordination training course or be willing to complete one prior to taking referrals.
- Proficient in MS Office and web -based services
Desirable
- Ability to provide motivational coaching to support peoples behaviour change
Qualifications
Essential
- Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health / health improvement
- 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 a Pharmacy setting
- Experience or training in personalised care and support planning
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
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.
