Anexciting opportunity has arisen within Primary Care for a Care Coordinator at The Confederation, Hillingdon CIC based at our Synergy PCN.
We have 1 vacancy available on a part-time permanent contract.
Care Coordinators playan important role within a PCN to proactively identify and work with people,including the frail/elderly and those with long-term conditions, to providecoordination and navigation of care and support across health and careservices.
They work closely withGPs and practice teams to manage a caseload of patients, acting as a centralpoint of contact to ensure appropriate support is made available to people andtheir carers; supporting them to understand and manage their condition and ensuringtheir changing needs are addressed.
This is achieved bybringing together all the information about a persons identified care andsupport needs and exploring options to meet these within a single personalisedcare and support plan, based on what matters to the person.
Care Coordinators couldprovide time, capacity and expertise to support people in preparing for, orfollowing-up, clinical conversations. Enabling them to be more activelyinvolved in managing their care and supporting them to make choices that areright for them. Care Coordinators help people improve their quality of life.
Main duties of the job
We recognise the value that a PCN Care Coordinator can bring to ourpractices and our aim is to provide exemplary patient care; finding innovativesolutions in general practice to deliver the best outcomes to our patients. Weare seeking an enthusiastic and forward-thinking PCN Care Coordinator to jointhe ever growing team .
The role will be to work within our network of GP Practices to providea central co-ordination role for patient care planning.
About us
The Confederation, HillingdonCIC works with General Practice and other healthcare providers to deliver itsvision for Hillingdon to deliver the best primary care outcomes for patientsin the whole of London. We are a not for profit community interestcompany. The Confederation works to develop and support individual GPpractices, PCNs and Neighbourhoods and their changing needs. We deliverexcellent clinical services ourselves both at scale and complementary toGeneral Practice. We are the provider representative voice for localGeneral Practice into the wider NHS and other Partners. We are of theNHS but independent, innovative and transformational.
The Confederation determinesto develop as an attractive place to work, providing rewarding roles andopportunities to grow in order to attract and retain great staff that in turndelivers our vision.
Our Values:
* We work together to make a difference for patients
* We care enough to go the extra mile
* We support, trust, and empower
* We sincerely value each other
* We support Primary Care to own its destiny
Job responsibilities
* Workwith people, their families and carers, to improve their understanding of theircondition.
* Supportpeople to develop and review personalised care and support plans to managetheir needs and achieve better healthcare outcomes.
* Helppeople to manage their needs by providing a contact to answer queries, make andmanage appointments, and ensure that people have good quality written or verbalinformation to help them make choices about their care.
* Assistpeople to access self-management education courses, peer support, healthcoaching and other interventions that support them in their health andwellbeing, and increase their levels of knowledge, skills and confidence inmanaging their health.
* Providecoordination and navigation for people and their carers across health and careservices. Helping to ensure patients receive a joined-up service and theappropriate support from the right person at the right time.
* Workcollaboratively with GPs and other primary care professionals within the PCN toproactively identify and manage a caseload, which may include patients withlong-term health conditions, and where appropriate, refer back to other healthprofessionals within the PCN.
* Supportthe coordination and delivery of multidisciplinary teams with the PCN.
* Raiseawareness of how to identify patients who may benefit from shared decisionmaking and support PCN staff and people to be more prepared to have shareddecision-making conversations.
* Take referrals orproactively identify people who could benefit from support through carecoordination.
* Have positive, empatheticand responsive conversations with people and their families and carer(s), abouttheir needs.
* Increasing patientsunderstanding of how to manage and improve health and wellbeing by offeringadvice and guidance.
* Develop an in-depthknowledge of the local health and care infrastructure and know how and when toenable people to access support and services that are right for them.
* Use tools to measurepeoples levels of knowledge, skills and confidence in managing their healthand tailor support to them accordingly.
* Support people to developand implement personalised care and support plans.
* Review and updatepersonalised care and support plans at regular intervals.
* Ensure personalised careand support plans are communicated to the GP and any other professionalsinvolved in the persons care and uploaded to the relevant online care records,with activity recorded using the relevant SNOMED codes.
* Make and manageappointments for patients, related to primary care.
* Help people transitionseamlessly between secondary and community care services, conducting follow-upappointments, and supporting people to navigate through the wider health andcare system.
* Refer onwards to socialprescribing link workers and health and wellbeing coaches where required and toclinical colleagues where there is an unaddressed clinical need.
* Regularly liaise with therange of multidisciplinary professionals and colleagues involved in thepersons care, facilitating a coordinated approach and ensuring everyone iskept up to date so that any issues or concerns can be appropriately addressedand supported.
* Actively participate inmultidisciplinary team meetings in the PCN.
* Identify when action oradditional support is needed, alerting a named contact in addition to relevantprofessionals, and highlighting any safety concerns.
* Record what interventionsare used to support people, and how people are developing on their health andcare journey.
* Workwith your supervising GP and/or line manager (if different) to undertakecontinual personal and professional development, taking an active part inreviewing yearly progress, and developing the roles and responsibilities anddeveloping clear plans to achieve results within priorities set by others.
* Workwith your supervising GP to access regular clinical supervision, to enableyou to deal effectively with the difficult issues that people present.
* Involved inone-to-one meetings with line manager regularly to discuss targets and outcomesachieved.
* Establish strong workingrelationships with GPs and practice teams and work collaboratively with othercare coordinators, social prescribing link workers and health and wellbeingcoaches, supporting each other, respecting each others views and meeting regularlyas a team.
* Act as a champion forpersonalised care and shared decision making within the PCN.
* Demonstrate a flexibleattitude and be prepared to carry out other duties as may be reasonablyrequired from time to time within the general character of the post or thelevel of responsibility of the role, ensuring that work is delivered in atimely and effective manner.
* Identify opportunities andgaps in the service and provide feedback to continually improve the service andcontribute to business planning.
* Contribute to thedevelopment of policies and plans relating to equality, diversity and reductionof health inequalities.
* Adhere toorganisational, practices and PCN policies and procedures, includingconfidentiality, safeguarding, lone working, information governance, equality,diversity and inclusion training and health and safety.
* Contribute to the wideraims and objectives of the PCN to improve and support primary care.
Person Specification
Qualifications
* GCSE in English and Math
* IT literacy
Experience
* Experienced Care Coordinator with EMIS experience
* 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
* Ability to identify risk and assess / manage risk when working with individuals
* 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 provide motivational coaching to support peoples behaviour change
* Demonstrable commitment to professional and personal development
* Completed a two day PCI accredited care coordination training course or be willing to complete one prior to taking referrals.
* Proficient in MS Office and web -based services
* Excellent interpersonal, influencing and negotiating skills.
* Excellent written and verbal communication skills
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.
£25,000 to £33,000 a yearDependent on Experience
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