Job Summary:
The Care Coordinator will be part of the Primary Care Network (PCN) Multi-Disciplinary Team (MDT) who are responsible for managing the care of people registered with practices within a particular PCN. This will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population.
The Care Coordinator will work within their expertise as part of a multi-disciplinary team to provide expertise in developing robust IT systems and information management across several Practices to help implement efficient services, maximise income and produce quality reporting.
Roles and Responsibilities:
* Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids.
* Bring together a person's identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with person-centred service plan (PCSP) best practice.
* Help people to manage their need, answering their queries and supporting them to make appointments.
* Ensure that people have good quality information to help them make choices about their care
* Support people to understand their level of knowledge, skills and confidence (*Patient Activation" level) when engaging with their health and wellbeing, including through use of the patient activation measure
* Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing
* Explore and assist people to access personal health budgets where appropriate
* Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
* Establish good working relationships with people employed in Practices across the PCN to enable them to carry out their duties effectively. It is important that the skills of existing teams continue to be valued and their roles developed as agreed with the Practice.
* Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN.
Key Relationships
Key Working Relationships Internal:
* Clinical Lead.
* GPs and General practice teams within the PCN
* PCN Clinical Director
Key Working Relationships External:
* GPs from neighbouring PCNs
* Service providers
* Social care
* Voluntary services
* Patients/service users
* Carers/relatives
Person Specification Education, Qualifications and Training:
* Diploma/ HNC level (or relevant experience)
* Ongoing internal and external training to keep up to date with changes/ developments
* Long term conditions training (desirable)
* Welfare Rights basic training (desirable)
Experience and Knowledge Required:
* Minimum of 2 years' experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (desirable)
* 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
* Knowledge/familiarity with medical terminology
* Working in a busy and demanding environment whilst delivering in a timely manner
* Vulnerable adults' awareness (desirable)
* Experience of care of the elderly (desirable)
* Understanding of current issues facing the NHS (desirable)
* Knowledge of social services structures Training in continuing care criteria (desirable)
* Understanding of health and social care processes (desirable)