Care Coordinator

Job description

Job responsibilities

Key Responsibilities

utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care

holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan, in line with PCSP best practice, based on what matters to the person

help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care

support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through the use of the Patient Activation Measure

assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level

provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals

support the coordination and delivery of MDTs within the PCN

Administrative Responsibilities

work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN

raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations

To work as a key member of the MDT to help support the development of effective MDT meetings.

Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers.

To ensure that action points identified within the MDT are recorded and followed up

Under guidance from their line manager, take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team

To cross reference the patients identified as high risk with the carers register within the practice to support case managers and key workers in developing holistic anticipatory care plans including prevention of carer breakdown

To work with the wider MDT to identify appropriate case managers for high risk patients to ensure that patients are reviewed and anticipatory care plans are developed

Ensure that all patients Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available

To liaise with acute hospitals, cross referencing admission data with the at risk list, and coordinating the sharing of key information between the acute hospital teams and the community services.

Work collaboratively with the PCN team

Develop relationships and work closely with community, hospital and MMT pharmacy colleagues and the wider health system

Liaise with other stakeholders for the collective benefit of patients

Attend relevant network and practice meetings

To analyse latest information and trends and subsequently present this in an appropriate format within practices to promote good practice

Demonstrate self-development through continuous professional development

In Accordance with the Risk Management Strategy, employees will participate, whenever required, with the risk management process. They will support line managers by attending mandatory and statutory training, completing incident/accident forms for every adverse event or near miss that occurs, report all defects and complaints, and communicate any dangerous situation to individuals potentially at risk.

You must co-operate with those in authority and others in meeting the statutory requirements and in following policies and procedures. A copy of the Health and Safety Policy is available from your lead employer.

You are reminded that in accordance with the Health and Safety at Work Act 1974 you have a duty to take reasonable care to avoid injury to yourself and to others affected by your work activities.

Infection Control

All staff must comply with infection control policies and guidance, attend relevant updates and report issues of concern to their immediate line manager.

All employees have a duty to safeguard and promote the welfare of children and adults and are required to act in such a way that at all times safeguards their health and wellbeing. Familiarisation with and adherence to national and local safeguarding adults and children policies is an essential requirement upon all employees. Staff are also required to participate in related mandatory and statutory training.

This Job Description is not exhaustive and may change as the post develops, but such change will not take place without consultation between the post holder and management. Job descriptions should be reviewed at least annually at the appraisal meeting.

There is a need to travel between sites, therefore ability to drive and uses own car is an advantage.

Person Specification

Experience

Essential

• Experience of working under own direction
• Experience in a patient focused environment
• Experience of planning and organising complex meetings/agendas

Desirable

• Experience or working within General Practice
• Experience of supporting service improvement
• Experience of using a medical software package - EMIS

Qualifications

Essential

• NVQ Level 3 or equivalent level of knowledge in office procedures
• Evidence of commitment to continuing professional development

Sills and Kowledge

Essential

• Evidence of working with IT systems
• Evidence of ability to support collation and analysis of data
• Excellent verbal and written skills
• Ability to provide and receive complex information
• Excellent interpersonal skills
• Demonstrable ability to show kindness and compassion
• Demonstrate ability to reflect and learn from situations
• Identifies difficulties as challenges and works with others to identify solutions
• Demonstrates cooperative team working and awareness of the roles of other professionals
• Able to work on own initiative, organising and prioritising own workload to set deadlines
• Ability to adapt and change approach as circumstance dictates
• Persistence and ability to keep going in difficult situations and with complex and uncertain pieces of work
• Understanding of and commitment to equality of opportunity and good working relationships
• Can do attitude, able to maintain positivity in the face of adversity
• Good time keeping
• Flexible approach to work
• Ability to work flexibly across days of the week
• Demonstrates ability to motivate self and use own initiative to achieve goals
• Adaptable
• Willing and able to travel throughout the eight practices within iGPc, as required
• Good computer literacy

Desirable

• Proven track record of effective use of networking and influencing skills

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

IGPC Primary Care Network

Address

Belle Vale Health Centre

Hedgefield Road

Liverpool

L25 2XE

Employer's website

https://igpc-liverpool.nhs.uk/ (Opens in a new tab)