Care Coordinator-Health Inequalities and Long Term Conditions
Job Description
Job summary
An exciting opportunity has arisen to join Shoreditch Park & City PCN as a Care Coordinator. If you are a dynamic individual who is passionate about tackling health inequalities, and interested in developing your career in primary care, then we would love to hear from you.
Groups of GP Practices in City and Hackney have recently come together to form 8 Primary Care Networks (PCNS) each covering a total population of between 30,000 - 58,000. The purpose of these PCNs is to enable GP practices to work together in a collaborative way to develop and deliver network-based services that respond to the needs of the local population.
Tackling health inequalities are core focuses for the PCN, and we are looking for a candidate that will be able to work with supporting the needs of vulnerable patients this job will be particularly focused on patients facing inequalities incl. learning disabilities, Long term conditions and those from diverse cultural and social backgrounds. The role will also be focusing on identifying and supporting carers within the PCN.
Main duties of the job
Working closely with GPs and other primary care professionals within the PCN, you will identify and manage a caseload of identified patients, making sure that appropriate support is made available to them, whilst ensuring that their changing needs are addressed.
Knowledge on the Care Act, Mental Capacity Act, safeguarding and other relevant national and local guidelines would be beneficial. You will be working closely with the local health providers, and other charities, and social care organisations, in support of these patients care and wellbeing.
You will focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities and population health management risk stratification. As a care coordinator, you will provide expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. You will be the point of liaison for patients and interface with all health and social care professionals, including keeping everyone informed and updated. The post holder will work as part of a multi- disciplinary team in a patient-facing role.
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.
About us
About Shoreditch Park & City PCN:
Shoreditch Park & City PCN are a friendly group of five Practices supporting a diverse population in both the City of London & Hackney. The post holder will work collaboratively with a multidisciplinary health & social care team to support and provide holistic treatment and care for our diverse population groups.
Job responsibilities
As a PCN Health Inequalities and Long Term Conditions Care Coordinator, you will play a vital role in helping individuals with health inequalities regain stability and improve their quality of life. Your main and overall responsibilities will include:
Assessment and Planning: Conduct assessments of patients needs and develop Personalised Care Support Plans (PCSPs).
Needs Assistance: Ensure patients are getting their annual health checks completed, supported in participation of national vaccination and cancer screening programmes, and assisted in accessing any other services that they may need
Advocacy: Advocate on behalf of patients to access essential services, benefits, and housing opportunities. This includes supporting them to feel comfortable in attending their appointments & making reasonable adjustments.
Referral Services: Connect patients to relevant community resources, health and social care, local carers support service, community navigation and working with and other healthcare & mental health services
Documentation: Maintain accurate and up-to-date patient records and progress reports.
The Care Coordinator responsibilities include but are not limited to the following:
To work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients
In collaboration with clinicians, administrative and reception team colleagues, to help patients with complex needs navigate the health and care system. This includes helping them 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 patients to utilise decision aids, help create single personalised care and support plans, in line with best practice.
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 (PCSP), in line with PCSP best practice, based on what matters to the person.
Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure (PAM)
Provide coordination and navigation for people and their carers across health and care services, including the use of digital tools.
Support people to take up training and employment, and to access appropriate benefits where eligible;
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
Explore and assist people to access personal health budgets, where appropriate.
Work closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Other key relationships include: City and Hackney Neighbourhood team, GP Confederation, social care, secondary care (Homerton and ELFT), community services, community and Clinical Pharmacists, City and Hackney CCG, Hackney Community and Voluntary sector and fellow care coordinators.
Support the Clinical directors in the delivery of the DES specifications and support practices to reach proactive care targets
Support practices in engaging patients in initiatives such as cancer screening, LTC checks, vaccination & immunisation uptake.
Engage, attend and link in with the PCN community navigation team and the wider neighbourhood MDT meetings.
EDUCATION, LEARNING AND DEVELOPMENT
There is a requirement to comply with all organisational and statutory requirements (e.g. health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance).
You will engage with appropriate training for Care Coordinators as set out by the Personalised Care Institute
There is a requirement to engage in annual appraisal, developing objectives to inform a Personal Development Plan, which may include 360-degree appraisal and use of patient feedback.
Support the practice staff and respond to requests for advice and assistance.
Undertake additional training where necessary to provide enhanced services and participate in training programmes implemented by the PCN/practices as part of this employment.
CONFIDENTIALITY
In the performance of the duties outlined in this Job Description, the post-holder will have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the network. All information is to be regarded as strictly confidential.
Maintain confidentiality of any information concerning patients in accordance with current policy on information governance.
Demonstrate respect for privacy and confidentiality in all interactions with patients and the public.
DATA PROTECTION
If you are required to obtain, process and/or use information held electronically you should do 'it in a fair and lawful way. You should hold data only for the specific registered purpose and not use or disclose it in any way incompatible with such a purpose. Data must only be disclosed to authorised persons or organisations as instructed.
SAFEGUARDING ADULTS AND CHILDREN
The postholder has a duty to safeguard and promote the welfare of vulnerable adults and children.
When adults or children and/or their carers use primary care services, it is essential that all adult and child protection concerns are both recognised and acted on appropriately.
The postholder has a responsibility to ensure they are familiar with and follow local policies in relation to safeguarding vulnerable adults and that they follow the local child protection procedures and any supplementary guidance.
The postholder has a responsibility to support appropriate investigations either internally or externally.
To ensure the ...
