This is an exciting opportunity for theright person who wants to work supporting patients by coordinating theirhealth and social care services. Based in a GP practice, the care coordinatorwill be involved in supporting the clinical team to proactively identify andwork with patients, including the frail/elderly and those with long-termconditions, to provide proactive, person-centred care planning, helpingcoordinate care, by bringing together the different specialists whose help thatindividual might need. This might involve a wide range of services, such ashospital care, community care, social care, housing and the voluntary sector.
Main duties of the job
Duties include:
Work with individual patients, their families and carers, using a holistic approach, to identify their goals for care, and agree a personalised care and support plan for their care
Work with individual patients, their families and carers, using a holistic approach, to identify their goals for care, and agree a personalised care and support plan for their care
Support delivery of these care plans by co-coordinating input from a range of different professionals and services, and helping patients and their carers/family to navigate across health and social care services
Work as part of the primary care team, coordinating care between GPs, practice nurses, clinical pharmacists, social prescribing link worker and health coach
Help patients to manage their needs through answering queries, being a first point of contact in the practice, and by making and managing appointments
Undertake regular reviews of the personalised care and support plans developed with patients
Work in line with national best practice when developing personalised care and support plans
Work with patients over the phone and in person in the practice.
About us
The main surgery is situated at 11 Wilson Street, Derby, centrally located and a short uphill walk from the city centre. We have two branch surgeries: Taddington Road Surgery, Chaddesden, Derby, and St Thomas Road Surgery, 207 St Thomas Road, Derby. Clinicians consult from all sites. The Practice is well established; it is the oldest surgery in Derbyshire, and there has been a surgery on the Wilson Street site since 1895. Many of our patients families have been registered for fifty years or more.
We are a growing Practice covering virtually the whole of Derby. Our patients have a range of medical issues reflecting health inequalities due to a mix of social and deprivation problems. We also have a wide range of ethnic diversity in our patients.
Job responsibilities
A Patient Care Coordinator can provide capacity and expertise to support patients in preparing for clinical conversations they have with primary care professionals to free up time for the clinician, highlight any issues or blocks to continuing health at an early stage and act as a link between the patient, the clinician and any outside or partner agency.
The role also supports the booking of appointments, setting up of group consultations, administration of clinics and the management of population health initiatives.
The role acts as a liaison between the clinician, admin team and the patient and can be seen as a primary care version of a Patient Advise and Liaison Service (PALS) which has been run successfully in Secondary Care for some time.
The Patient Care Coordinator will work closely with the GPs and other primary care professionals within the practice to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
Person Specification
Skills and Knowledge
* Understanding of and commitment to equality, diversity and inclusion
* Ability to maintain strict code of confidentiality at all times
* Knowledge of policies and procedures, including safeguarding, information governance and health and safety
* Knowledge of how the wider NHS works, including PCNs
* Knowledge of long term conditions and the complexities involved medical, physical, emotional, and social
Qualifications
* 5 GCSE passes at Grade 9-4 / A*-C or equivalent including English & Maths
* Higher level qualification such as NVQ in adult care Level 3
* Qualification relevant to health or social care
Personal Qualities and Attributes
* Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
* Ability to provide a culturally sensitive service supporting patients from all backgrounds and communities, respecting lifestyles and diversity
* Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
* Ability to communicate effectively, with a wide variety of people
* Ability to identify risk and assess/manage risk when working with individuals
* Has an understanding of when it is appropriate to refer patients back to other health professionals/agencies, and of the limit of their own competencies
* Ability to work collaboratively as part of a team
* Demonstrates personal accountability, emotional resilience and works well under pressure
* Able to organise, plan and prioritise and work on own initiative
* Sound written and verbal communication skills
* Shows commitment to professional and personal development
* Willingness to work flexible hours when required to meet work demands
* Ability to think flexibly, work under pressure, prioritise, including maintaining a calm demeanour when dealing with conflict
* Proficient speaker of another language other than English
Experience
* Experience of working in health, social care and other support roles in direct contact with people, families or carers
* Experience of working in a multi-professional team environment
* Confident in using Email and sound IT knowledge
* Good written English and excellent record keeping skills
* Good communication skills, face to face and over the telephone. Ability to deal appropriately with difficult situations
* Experience of working in primary care
* Experience of working as a care coordinator
* Experience or training in personalised care and support planning
* Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
* Proficient in use of Systmone
* Experience of working with reports in Systmone
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.
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