Job summary
The Care Coordinator will work as part of a
multidisciplinary team (MDT) within a GP practice to identify people in need of proactive
support. This could be, for example, people who are frail or have multiple
long-term physical and mental health conditions.
They work with people individually, building
trusting relationships and listening closely to what matters to them to develop
a personalised care and support plan. This includes reviewing their needs and
helping to connect them to the services and support they require within the
practice or elsewhere, for example community and secondary services.
Another key part of the role is to provide support
for people who are preparing for clinical conversations with healthcare
professionals or following up on those conversations, to ensure they can be
actively involved in managing their care and supported to make choices that are
right for them. Care coordinators work closely with GPs and practice teams to
help manage caseloads. They act as a central point of contact so that
appropriate support can be made available to individuals and their carers which
helps them to manage their condition and addresses their needs.
Main duties of the job
The care coordinator
is to play a key role in
proactively identifying and working with people, including the frail/elderly
with long-term conditions, to provide coordination and navigation of care and
support across health and care services.
The
Practice Care coordinator will provide senior support to the practice team in
targeting hard to reach groups with a focus on inequalities including Core20
Plus 5 groups andand
patients.
The Care Coordinator will review
peoples identified needs and help to connect them to the services and support
they require, whether within the practice or elsewhere for example, community
and hospital-based services.
Working closely with social prescribing link workers, health and
wellbeing coaches, and other primary care professionals' team to provide an all-encompassing
approach to personalised care and enable people navigate through the health and
care system.
Identifying target areas such as long-term conditions, frailty, DES, QOF
and IIF targets. Support practices in achieving their recall targets and
providing an enhanced outreach service to those hard-to-reach groups.
Identifying patients requiring proactive support i.e., hard to reach
patients, high risk patients as identified in MDTs/practice meetings.
Working with patients to improve their access to primary care services
and comply with the requirements of the PCN Capacity and Access Improvement
plan including the transformation elements of new triage processes.
About us
Sunderland GP Alliance is a not-for-profit collaboration of GP practices in Sunderland.
All GP Practices in Sunderland are members of the organisation, covering approximately 285,000 patients.
The Alliance also runs three practices in Washington, South Hylton and New Silksworth.
Formed in 2015, Sunderland GP Alliance is an organisation owned by the GP Practices of Sunderland, it exists to help GPs work collaboratively for the benefit of patients and staff.
All GP practices in Sunderland are members of the organisation. The Alliance works on a not-for-profit basis, ensuring any surplus is reinvested back into better services for patients.
Organisations such as ours help General Practice respond to the changing needs of the health system. Many of the services we provide cannot be delivered by individual GP surgeries. Our COVID vaccination programme, our community integrated team support and our enhanced access service are all good examples of this; In the enhanced access service only by working together with all the practices can we offer patients the convenience of appointments with members of the GP team on weekday evenings and during the day on weekends in locations across the city within their neighbourhoods. This is often referred to as federated working.
Job description
Job responsibilities
Main Duties and
Responsibilities
Safeguarding
- To comply with local safeguarding
processes for children and vulnerable individuals.
Health and Safety
- To comply with the Health and
Safety at Work etc Act 1974
- To take responsibility for his/her
own health and safety and that of other persons who may be affected by his/her own
acts or omissions.
- Making effective use of training
to update knowledge and skills.
- Using appropriate infection
control procedures, maintaining work areas in a tidy and safe way and free from
hazards.
- Reporting potential risks
identified.
Equality
and diversity
The post-holder will support the
equality, diversity and rights of patients, carers, and colleagues by:
- Acting in a way that recognises the
importance of peoples rights, interpreting them in a way that is consistent
with practice procedures, policies, and current legislation.
- Respecting the privacy, dignity, needs
and beliefs of patients, carers, and colleagues.
- Behaving in a manner which is
welcoming.
- Behaving in a manner that is
non-judgmental and respects circumstances, feelings, priorities, and rights
Risk Management and Clinical Governance
- To
work within the Clinical Governance Framework of the GP Practice, incorporating
Risk Management and all other quality initiatives
General
- To undertake any other duties
commensurate with the role, within the bounds of his/her own competence
The post holder is expected to be flexible and
accommodating, following consultation, in terms of any changes in the future.
CONFIDENTIALITY
- In
the performance of the duties outlined in this job description, the post-holder
may have access to confidential information relating to patients and their
carers, Practice staff and other healthcare workers. All such information from any source is to be
regarded as strictly confidential.
- Information
relating to patients, carers, colleagues, other healthcare workers or the
business of the Alliance may only be divulged to authorized persons in
accordance with the Alliances policies and procedures relating to
confidentiality, and the protection of personal and sensitive data.
Quality
The
post-holder will strive to maintain quality within the Alliance, and will:
-
Alert other team members to issues
of quality and risk.
- Assess own performance and take
accountability for own actions, either directly or under supervision.
-
Contribute to the effectiveness of
the team by reflecting on own and team activities and making suggestions on
ways to improve and enhanced the teams performance.
- Work effectively with individuals
in other agencies to meet patients needs.
-
Effectively manage own time, workload,
and resources.
- Communication
- The
post-holder should recognize the importance of effective communication within
the team and will strive to:
-
Communicate effectively with other
team members.
-
Communicate effectively with
patients and carers.
-
Recognise peoples needs for
alternative methods of communication and respond accordingly.
Other
-
Undertake any
tasks consistent with the level of the post and the scope of the role, ensuring
that work is delivered in a timely and effective manner.
-
Duties may
vary from time to time, without changing the general character of the post or
the level of responsibility.
Job description
Job responsibilities
Main Duties and
Responsibilities
Safeguarding
- To comply with local safeguarding
processes for children and vulnerable individuals.
Health and Safety
- To comply with the Health and
Safety at Work etc Act 1974
- To take responsibility for his/her
own health and safety and that of other persons who may be affected by his/her own
acts or omissions.
- Making effective use of training
to update knowledge and skills.
- Using appropriate infection
control procedures, maintaining work areas in a tidy and safe way and free from
hazards.
- Reporting potential risks
identified.
Equality
and diversity
The post-holder will support the
equality, diversity and rights of patients, carers, and colleagues by:
- Acting in a way that recognises the
importance of peoples rights, interpreting them in a way that is consistent
with practice procedures, policies, and current legislation.
- Respecting the privacy, dignity, needs
and beliefs of patients, carers, and colleagues.
- Behaving in a manner which is
welcoming.
- Behaving in a manner that is
non-judgmental and respects circumstances, feelings, priorities, and rights
Risk Management and Clinical Governance
- To
work within the Clinical Governance Framework of the GP Practice, incorporating
Risk Management and all other quality initiatives
General
- To undertake any other duties
commensurate with the role, within the bounds of his/her own competence
The post holder is expected to be flexible and
accommodating, following consultation, in terms of any changes in the future.
CONFIDENTIALITY
- In
the performance of the duties outlined in this job description, the post-holder
may have access to confidential information relating to patients and their
carers, Practice staff and other healthcare workers. All such information from any source is to be
regarded as strictly confidential.
- Information
relating to patients, carers, colleagues, other healthcare workers or the
business of the Alliance may only be divulged to authorized persons in
accordance with the Alliances policies and procedures relating to
confidentiality, and the protection of personal and sensitive data.
Quality
The
post-holder will strive to maintain quality within the Alliance, and will:
-
Alert other team members to issues
of quality and risk.
- Assess own performance and take
accountability for own actions, either directly or under supervision.
-
Contribute to the effectiveness of
the team by reflecting on own and team activities and making suggestions on
ways to improve and enhanced the teams performance.
- Work effectively with individuals
in other agencies to meet patients needs.
-
Effectively manage own time, workload,
and resources.
- Communication
- The
post-holder should recognize the importance of effective communication within
the team and will strive to:
-
Communicate effectively with other
team members.
-
Communicate effectively with
patients and carers.
-
Recognise peoples needs for
alternative methods of communication and respond accordingly.
Other
-
Undertake any
tasks consistent with the level of the post and the scope of the role, ensuring
that work is delivered in a timely and effective manner.
-
Duties may
vary from time to time, without changing the general character of the post or
the level of responsibility.
Person Specification
Qualifications
Essential
- Demonstrable commitment to personal and professional development
- Proficient in the use of Microsoft Office applications.
- Able to provide a culturally sensitive service supporting people from all backgrounds and communities respecting lifestyle and diversity.
- Must be a car driver.
Desirable
- Experience of working in general practice
- Knowledge of how the NHS works, primary care and PCN's.
Experience
Essential
- Excellent communication skills and an ability to engage successfully with a wide range of people at all levels.
- Experience of collecting and recording confidential information and data
- Ability to identify risk to self and others, Identifying and reporting safeguarding incidents.
- Ability to actively listen and empathise with people and provide personalised support in a non judgement way.
- Basic knowledge of long-term conditions and the complexities involved; medical, physical, emotional, and social.
- The ability to work calmly under pressure.
- The ability to adapt your leadership and management style to different situations.
- Experience of championing diversity and inclusion and promoting actions to make improvements to the experience of diverse groups
Desirable
- Experience of working in a multi setting complex programme environment
- Experience of working in a community setting
- Extensive knowledge of local services within a Sunderland through either living or working within one of the wider Sunderland settings.
- Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work
- Ability to provide motivational coaching to support people's behaviour change.
- NVQ Level 3 in adult care, advanced level or equivalent qualifications or working towards.
Motivation and Skills
Essential
- Outstanding organisational skills, able to prioritise and work to deadlines.
- Work effectively and collaboratively as part of a team but also autonomously.
- Promote and maintain good working relationships with a variety of external partners.
- Keep accurate records of discussions and clearly replicate discussions in writing.
- Work on own initiative but within constraints of the role
- Understanding of and commitment to equality, diversity, and inclusion
- Ability to competently use technology and IT systems including word processing, email, and the internet to create simple personalised plans with individuals
- Ability to work across multiple sites in the Sunderland area.
- Confident and comfortable with difficult situations
- Patient, friendly and approachable
- Able to work under pressure and emotionally resilient.
- Ability to work flexible hours which may include occasional evenings or weekends with notice.
Desirable
- Understanding the impact of economic and environmental factors on people's health and wellbeing
Person Specification
Qualifications
Essential
- Demonstrable commitment to personal and professional development
- Proficient in the use of Microsoft Office applications.
- Able to provide a culturally sensitive service supporting people from all backgrounds and communities respecting lifestyle and diversity.
- Must be a car driver.
Desirable
- Experience of working in general practice
- Knowledge of how the NHS works, primary care and PCN's.
Experience
Essential
- Excellent communication skills and an ability to engage successfully with a wide range of people at all levels.
- Experience of collecting and recording confidential information and data
- Ability to identify risk to self and others, Identifying and reporting safeguarding incidents.
- Ability to actively listen and empathise with people and provide personalised support in a non judgement way.
- Basic knowledge of long-term conditions and the complexities involved; medical, physical, emotional, and social.
- The ability to work calmly under pressure.
- The ability to adapt your leadership and management style to different situations.
- Experience of championing diversity and inclusion and promoting actions to make improvements to the experience of diverse groups
Desirable
- Experience of working in a multi setting complex programme environment
- Experience of working in a community setting
- Extensive knowledge of local services within a Sunderland through either living or working within one of the wider Sunderland settings.
- Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work
- Ability to provide motivational coaching to support people's behaviour change.
- NVQ Level 3 in adult care, advanced level or equivalent qualifications or working towards.
Motivation and Skills
Essential
- Outstanding organisational skills, able to prioritise and work to deadlines.
- Work effectively and collaboratively as part of a team but also autonomously.
- Promote and maintain good working relationships with a variety of external partners.
- Keep accurate records of discussions and clearly replicate discussions in writing.
- Work on own initiative but within constraints of the role
- Understanding of and commitment to equality, diversity, and inclusion
- Ability to competently use technology and IT systems including word processing, email, and the internet to create simple personalised plans with individuals
- Ability to work across multiple sites in the Sunderland area.
- Confident and comfortable with difficult situations
- Patient, friendly and approachable
- Able to work under pressure and emotionally resilient.
- Ability to work flexible hours which may include occasional evenings or weekends with notice.
Desirable
- Understanding the impact of economic and environmental factors on people's health and wellbeing
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
Additional information
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
