Care Coordinator
Job Description
Job summary
The successful candidate will play a role in proactively identifying and working with people, including young adults, frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
They will work closely with GPs and practice teams, making sure that appropriate support is made available to people; supporting them to understand and manager their condition and ensuring their changing needs are addressed. They will enable people to access the services and support they require to meet their health and wellbeing needs, helping to improve peoples quality of life.
They work alongside Social Prescribing Link workers and Health and Wellbeing coach to provide an all-encompassing approach to personalised care and enable people to navigate through the health and care system.
The postholder will work with a diverse range of people from different cultural and social backgrounds. The ability to work confidently and effectively in a varied and sometimes challenging environment is essential.
Main duties of the job
* Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalized care and support plans to manage their needs and achieve better healthcare outcomes.
* 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.
* 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.
* Identify unpaid carers and help them access services to support them;
* Maintain records of referrals and interventions to enable monitoring and evaluation 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* Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances.
* Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours.
* Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies.
About us
Chippenham Corsham and Box PCN is an enthusiastic, dynamic and friendly PCN that is made up of 5 surgeries, serving 64,00 patients.
We are constantly striving to improve patient pathways, health and care outcomes and we are developing innovative ways of working more closely together.
Job responsibilities
Enable Access to personalised care and support
a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination.
b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs.
c. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance.
d. 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.
e. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly.
f. Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register.
g. Support people to develop and implement personalised care and support plans.
h. Review and update personalised care and support plans at regular intervals.
i. Undertake telephone assessments, home visits and face to face appointments.
j. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
Coordinate and integrate care
a. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
b. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system, including form filling support where appropriate.
c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required.
d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
e. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate.
f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
g. Record what interventions are used to support people, and how people are developing on their health and care journey.
h. 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.
i. Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing.
j. Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives.
k. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
Person Specification
Skills and knowledge
Essential
- Knowledge of the personalised care approach.
- 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, including primary care and PCNs.
- Ability to recognise and work within limits of competence and seek advice when needed
- Basic knowledge of long-term conditions.
- and the complexities involved: medical, physical, emotional and social
- Understanding of the needs of older people / children & young adults/ adults with disabilities / long term conditions particularly in relation to promoting their independence.
Desirable
- Knowledge of Safeguarding Children and Vulnerable Adults policies and processes.
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.
- Experience of data collection and using tools to measure the impact of services.
Desirable
- Experience of working directly in a care coordinator role, adult health, children & young adults and social care, learning support or public health/health improvement.
- Experience or training in personalised care and support planning.
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
Qualifications
Essential
- Demonstrable commitment to professional and personal development is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute.
- Proficient in MS Office and web-based services.
Desirable
- NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards.
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
Chippenham, Corsham & Box Primary Care Network
Address
Springfield Community Campus
Beechfield Road
Corsham
Wiltshire
SN13 9DN
United Kingdom
Employer's website
https://www.hathawaysurgery.co.uk/chippenham-corsham-box-primary-care-network/ (Opens in a new tab)
