Care Coordinator

Integrated Care System; Highbridge; On-site; GBP 25,000 - 30,000; Full time

Job summary

A local healthcare organization in Highbridge is looking for a Care Coordinator to support patients with long-term conditions. The role involves collaborating with a multidisciplinary team to deliver personalized care plans and ensure timely health management. Ideal candidates will have strong interpersonal and communication skills, experience in healthcare environments, and a commitment to promoting independence and partnership working.

Qualifications

• Experience in use of databases.
• Proven record of excellent written and verbal communication skills.
• Knowledge of medical terminology.

Responsibilities

• Coordination of care for patients in a PCN.
• Arranging MDT meetings and ensuring their smooth running.
• Managing a caseload of patients identified through referrals.

Skills

Interpersonal skills

Communication

Teamwork

Analytical skills

Problem-solving

Education

Educated to GCSE level or equivalent

ECDL or equivalent

Tools

Microsoft Office

Databases

Job description

The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions. An ethos of promotion of independence and partnership-working is integral to this post.

Care coordinators provide extra time, capacity, and expertise to support patients in preparing for clinical conversations or in following up discussions with primary care professionals.

They play an important role within a Primary Care Network (PCN) to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

The role will ensure patient health and care planning is timely, efficient, and patient-centerd. 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.

Main duties of the job

Working closelywith colleagues within the primary care network (PCN) to identify and manage a caseload of patients, making surethat appropriate support is made available to them and their carers and ensuring that their changing needs are addressed. They focuson the delivery of personalised care to reflect priorities, healthinequalities or at-risk groups of patients

They can alsosupport PCNs in the delivery of Enhanced Health in Care Homes

Akey part of the role of a care coordinator role is with the One Team (MDT):improving the continuity of care by acting as a point of contact for, familiesand professionals, such as Multi-DisciplinaryTeam (MDT)members and in-reach specialists. This will involve coordinating the work ofhealthcare professionals and non clinical staff including volunteers and thirdsector agencies involved in the care of registered patients

Theywill support the MDT with the daily virtual home round through identificationof people in need of review, or collation of information on people requiring anMDT review

The post holder will also be responsible for a caseloadof patients identified through the MDT meetings. Support provided directly withpatients and their carers would include co-producing personalised plans,utilising decision aids, providing information and training opportunities,making appointments, coordination and navigation for people and their carersacross health and care services.

Please see attached Job description for further information

About us

PCNs (Primary Care Network) are groups of GP practices working more closely together, with other primary and community care staff and health and care organisations, providing integrated services

North Sedgemoor PCN covers 5 GP practices in North Sedgemoor, supporting approximately 47, 000 patients.

North Sedgemoor PCN is a forward thinking group of practices who believe in developing people who work with them in order to give the best possible care to the people of North Sedgemoor.The PCN in the process of developingnew models of care.

Care Coordinators are part of the Somerset Social Prescribing Model. The successful candidates will work alongside social prescribing link workers and Health Coaches to provide an all-encompassing approach to personalised care and enable people to work out how best to use the health and care system.

The role will involve working across the North Sedgemoor area.

Job responsibilities

The post holderwill contribute to tackling inequalities in health and social care particularlyregarding individuals with long-term conditions. An ethos of promotion ofindependence and partnership-working is integral to this post.

Carecoordinators provide extra time, capacity, and expertise to support patients inpreparing for clinical conversations or in following up discussions withprimary care professionals.

They play an importantrole within a PCN to proactively identify and work with people, including thefrail/elderly and those with long-term conditions, to provide coordination andnavigation of care and support across health and care services.

The role will ensurepatient health and care planning is timely, efficient, and patient-centred. This is achieved by bringing together all theinformation about a persons identified care and support needs and exploringoptions to meet these within a single personalised care and support plan, basedon what matters to the person.

Overall responsibility for arrangingthe daily PCN led MDT meetings and the smooth running of integrated care withinthe team setting. A key role of the Care Coordinator is to ensure that all newreferrals are identified, and information circulated to team members in advanceof the meeting.

Take notes of MDT meetings anddisseminate; chase progress against actions identified in these meetings andensure follow up where necessary.

Patient Identification: Utilisepopulation health intelligence to proactively identify and work with a cohortof patients to deliver personalised care.

Receive and collate information fromtransfers of care (including hospital admissions and discharges) plus out ofhours calls and present this information to the MDT as required.

Liaise with service providers andclinicians to identify frequent flyers, and new service users utilising riskstratification tools provided and present this information to the daily MDTmeetings.

Support the completion of newreferrals by checking criteria, and where criteria have been met, directreferral to the MDT.

Signpost team members, service usersand carers to relevant services

Manage a caseload of patientsidentified through the MDT or practice.

Support patients to utilise decisionaids in preparation for a shared decision-making conversation.

Holistically bring together all of apersons identified care and support needs and explore options to meet thesewithin a single personalised care and support plan (PCSP), in line with PCSPbest practice, based on what matters to the person.

Help people to manage their needsthrough answering queries, making and managing appointments, and ensuring thatpeople have good quality written or verbal information to help them makechoices about their care.

Support people to take up trainingand employment, and to access appropriate benefits where eligible.

Support people to understand theirlevel of knowledge, skills and confidence (their Activation level) whenengaging with their health and wellbeing, including through the use of thePatient Activation Measure.

Assist people to access self-managementeducation courses, peer support or interventions that support them in theirhealth and wellbeing and increase their activation level.

Explore and assist people to accesspersonal health budgets where appropriate.

Refer or liaise with the HealthCoaches and Village Agents as appropriate.

Communication and collaborativeworking relationships

Demonstratesability to work as a member of a team.

Canrecognise personal limitations and refer to more appropriate colleague(s) whennecessary.

Activelywork toward developing and maintaining effective working relationships bothwithin and outside the PCN or group of PCNs.

Liaiseswith other stakeholders as needed for the collective benefit of patientsincluding but not limited to Patients GP, Nurses, other practice staff andother healthcare professionals including pharmacists and pharmacy techniciansfrom provider and commissioning organisations.

Work with service users, PCNpractices and partners e.g., Care Homes to ensure new referrals are logged andallocated.

Develop excellent workingrelationships with all partners, wider service networks including the voluntarysector, GP practices, adult social care, hospitals, community pharmacists andother members of the MDT.

Acting as a point of contact forresidents, families, carers and professionals who visit the care home, such asMDT members and in-reach specialists.

Meet regularly with the clinical leadand review case load and MDT function.

Keep the MDT and OHP organisationabreast of good news stories.

Provide background information aboutindividuals for the daily MDT meetings.

Communicate effectively with serviceusers and their families/carers, and provide coordination across health andcare services working closely with social prescribing link workers, health andwellbeing coaches, and other primary care professionals.

Manage and prioritise workload on adaily basis and deal with the competing demands of the MDT

Other responsibilities

To always act in ananti-discriminatory manner

To be able to plan and respond toworkload according to operational priorities.

To support the delivery of thesefunctions across wider locality areas where necessary

To undertake any training required tomaintain competency including mandatory training.

To contribute to, and work within asafe working environment.

The Care Coordinator must at alltimes carry out duties and responsibilities with due regard to the GPPractices equal opportunity policies and procedures.

The Care Coordinator is expected totake responsibility for self-development on a continuous basis, undertakingon-the-job training as required.

The Care Coordinator must be aware ofindividual responsibilities under the Health and Safety at Work Act, andidentify and report as necessary any untoward accident, incident or potentiallyhazardous environment.

Communicate effectively andsensitively and use language appropriate to a patient and carer/relativescondition and level of understanding.

Effectively use all methods ofcommunication and be aware of and manage barriers to communication.

Effectively recognise and managechallenging behaviors, carers and or relatives

Provide information to patients,their carers and/or relatives on behalf of the team.

The PCN will ensure the PCNs CareCoordinator can discuss patient related concerns and be supported to followappropriate safeguarding procedures (e.g., abuse, domestic violence and supportwith mental health) with a relevant GP.

Supporting Care Delivery

Be the point of liaison for serviceusers and interface with all health and social care professionals, includingkeeping everyone informed and updated.

Follow through actions identified bythe MDT including arranging tests, referrals, signposting, etc.

Follow through with service users andothers involved to ensure all services and care arrangements are in place.

Autonomy/Scope within Role

The post holder will be required towork within clearly defined organisational protocols, policies and procedures.

Key Relationships

Key Working Relationships Internal:

ClinicalLead for the MDT

GPs andGeneral practice teams within the PCN

MDTmembers including but not exhaustive: Clinical Pharmacists, technicians,District Nurses, LARCH Team, OPMH, IRT, Adult Social Care, Paramedics, SocialPrescribing Link Workers, Village Agents

Key Working Relationships External:

GPs fromneighbouring PCNs

Serviceproviders

Voluntaryservices

Carers/relatives

Person Specification

Other

• Access to and ability to use transport as travel between sites across the county will be required for work, meetings and training.
• Professional attitude and assertive approach
• Committed to development.
• Conscientious, hardworking and self- motivated to work with minimal supervision.
• Creative and tenacious in finding solutions to difficult problems.
• Ability to work with information, clinicians, social workers and managers.
• Ability to meet deadlines and work under pressure.
• Ability to engage and sustain relationships with all professionals, other organisations and service-users.
• Approachable and flexible
• Honest and reliable
• Sensitive to patients needs.
• Willingness to undergo further training or development.

Qualifications

• Educated to GCSE level or equivalent
• ECDL or equivalent

Experience

• Experience in use of databases
• Experience of administrative duties
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
• Working in a multi-disciplinary setting where influence and negotiation is required.
• Working in a busy and demanding environment whilst delivering in a timely manner
• Proven record of excellent written and verbal communication skills and interpersonal skills
• Evidence of excellent knowledge of Microsoft Office
• Able to deal with service users sensitively.
• Able to work as part of a team.
• Able to prioritise and manage own workload.
• Excellent motivational and influencing skills.
• Strong analytical and judgement skills
• Ability to analyse and interpret information and present results in a clear and concise manner.
• Excellent organisational and administration skills
• Experience providing advice/signposting to users.
• Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (desirable)
• Knowledge/familiarity with medical terminology
• Understanding of current issues facing the NHS
• Understanding of health and social care processes
• Able to use NHS Choices website effectively

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.