Care Coordinator

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
• Help people to manage their needs by providing a contact to answer queries and ensure that people have good quality written or verbal information to help them make choices about their care
• Work with people, their families and carers, to improve their understanding of their condition
• Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health
• 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
• Use tools to measure people's levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly
• Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations

Co-ordinate and Integrate care

• Provide co-ordination and navigation for people and their carers across health and care services, helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time
• Help people transition seamlessly between secondary and community care services, supporting people to navigate through the wider health and care system
• Conduct follow-ups on communications from out of hospital and in-patient services
• 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 person's 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
• Support the co-ordination and delivery of multidisciplinary teams within the PCN
• Support the PCN in developing communication channels between GPs, people and their families and carers, and other agencies
• Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours
• Identify carers and help them access services to support them

Record Keeping, Monitoring and Evaluation

• Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes
• Record what interventions are used to support people, and how people are developing on their health and care journey
• Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation
• Maintain records of referrals and interventions to enable monitoring and evaluation of the service
• Work sensitively with people, their families and carers to capture key information, while tracking the impact of care co-ordination on their health and wellbeing
• Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service
• Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances

Teamworking, Community and Service Development

• 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 other's views and meeting regularly as a team
• Act as a champion for personalised care and shared decision making within the PCN
• Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives.
• 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.
• Contribute to the wider aims and objectives of the PCN to improve and support primary care
• Identify gaps in local service provision through conversations with people and communities, working with your line manager, colleagues and community stakeholders to explore and develop potential responses this may include supporting the development of new community groups or partnership projects
• 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

ALL POST HOLDERS ARE REQUIRED TO

• Adhere to West Mendip PCN policies and procedures, e.g. Health and Safety at Work, Equal Opportunities etc.

• Maintain personal and professional development to meet the changing demands of the job, participate inappropriate training activities and encourage and support staff development and training
• Attend statutory, essential and mandatory training
• Take part in an annual appraisal
• Respect the confidentiality of all matters relating to their employment and other members of staff. All members of staff are required to comply with the requirements of the Data Protection Act 2018
• Comply with the codes of professional conduct set out by the professional body should registration be required for the post
• Maintain the prevention and control of infection and fully comply with all current Infection Control policies and procedures
• Take responsibility for any records that they create or use in the course of their duties, in line with the Public Records Act and be aware that any records created by an employee of the NHS are public records and may be subject to both legal and professional obligations
• Perform general administrative duties such as locating of clinical files and working with the administrative team as required
• Document in patient notes in the agreed PCN format
• Report untoward incidents such as complaints, clinical emergencies or injury to senior staff
• Strive to maintain quality within the PCN, and 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 enhance the teams performance
• Work effectively with individuals in other services and organisations to meet patients' needs
• Effectively manage own time, workload and resources

NOTE

This job description is not intended to be exhaustive and may be updated to reflect evolving service needs, following consultation with the post holder. All duties are to be carried out in accordance with West Mendip PCN policies, procedures and guidelines. Routine operational changes do not require amendment.

UNDERPINNING POLICIES

The post holder is expected to maintain confidentiality, uphold equality and diversity, and comply with safeguarding, health and safety and risk management requirements at all times. They should take part in personal and professional development, contribute to quality improvement, and communicate effectively with colleagues, other organisations and services, and the people they support, in line with PCN standards and legal obligations. The role also requires accurate and secure record keeping in accordance with the Data Protection Act, Freedom of Information Act and other relevant legislation.

Person Specification

Qualifications

Essential

• 5 GCSEs or equivalent, to include English and Maths: A*- C or 9 - 4 grade

Personal Attributes

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
• 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 Coordinator 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
• Proficient in MS Office and web-based services

Other Requirements

Essential

• Hold a current UK driving licence and have access to a vehicle that is insured for business purposes
• Able to work across multiple sites as required
• Willingness to work flexibly to support occasional events or activities outside normal working hours

Desirable

• Proficient speaker of another language to aid communication with people in the community for whom English is a second language

Skills and Knowledge

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
• Knowledge of how the NHS works
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Ability to recognise and work within limits of competence and seek advice when needed

Desirable

• Experience using EMIS
• Experience using RiO
• Knowledge of primary care and PCNs
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes
• Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social

Experience

Essential

• 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

Desirable

• Experience of working directly in a care co-ordination role, adult health and social care, learning support or public health / health improvement
• Experience of data collection and using tools to measure the impact of services
• 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.

Employer details

Employer name

West Mendip Primary Care Network

Address

St Dunstan's House Community Health & Wellbeing Centre

Glastonbury

BA6 9EL

Employer's website

https://www.westmendippcn.co.uk (Opens in a new tab)