Care coordinators play a varied andimportant role within our practices. Theirprimary function is to work with along side and with our clinical triage teamto coordinate the care for our practice patient population and ensure the rightcare at the right time.
Care coordinators review patientsneeds and help them access the services and support they require to understandand manage their own health and wellbeing, referring to social prescribing linkworkers, health and wellbeing coaches, and other professionals whereappropriate.
This role is intended to become anintegral part of the practices multidisciplinary team, working alongside socialprescribing link workers and health and wellbeing coaches to provide anall-encompassing approach to personalised care and promoting and embedding thepersonalised care approach across the PCN. There may be a need to work remotelydepending on the requirements of the role.
Please note that the role of a carecoordinator is not a clinical role.
Main duties of the job
Help people to manage their needs through answeringqueries, making and managing appointments, and ensuring that people have goodquality written or verbal information to help them make choices about theircare.
Work collaboratively with GPs and other primary careprofessionals within the practice to proactively identify and manage acaseload, which may include patients with long-term health conditions, andwhere appropriate, refer back to other health professionals at our PCN orwithin our community service.
Work with people, their families, carers and healthcareteam members to encourage effective help-seeking behaviours.
Support our digital team in developing communicationchannels between GPs, people and their families and carers and other agencies.
Maintain records of referrals and interventions toenable monitoring and evaluation of the service. Conduct follow-ups on communications from out ofhospital and in-patient services.
Maintain records of referrals and interventions toenable monitoring and evaluation of the service.
Support practices to keep care records up to date byidentifying and updating missing or out-of-date information about the persons circumstances.
Contribute to risk and impact assessments, monitoringand evaluations of the service.
Workwith commissioners, integrated locality teams and other agencies to support andfurther develop the role.
About us
We provide General MedicalServices to our patients from 2 sites in Southend:
Tel 01702 582670
North Shoebury Surgery,Frobisher Way, Shoeburyness, Essex SS3 8UTTel 01702 297976
Working together inpartnership with our Primary Care Network to deliver services to their patient population across bothpractice sites, the practice is clinically lead by a GP and an Advanced ClinicalPractitioner, the partners are supported by a diverse clinical team made up ofsalaried GPs and part time locum GPs, Advanced Nurse Practitioners, AssociateNurse Practitioners, Prescribing Paramedics, Practice nurses, GP NurseAssistant, Health Care Assistants, a Lead Pharmacy Technician, PharmacyTechnicians, and a Prescription Clerks.
The administration teamcomprise of Care Navigators, Care Co-Ordinators, Medical secretaries, administrationstaff, Assistant Manager, Practice Manager, Primary care Development Managerand Business Manager with a list size in excess of 15,500 patients.
We are very proud to be a Training Practicesupporting GP and Nurse Training across South East Essex.
Whilst our practiceregistration is growing, we strive to provide high quality, safe, efficient,and effective service within the resource allocated to the practice. With particular focus on the prevention ofdisease by promoting health and wellbeing, offering care and advice to ourpatients.
Job responsibilities
Enable access to personalised care and support
Take referrals for individuals or proactively identifypeople who could benefit from support through care coordination.
Have a positive, empathetic and responsive conversationwith the person and their family and carer(s) about their needs.
Work towards increasing patients understanding of howto manage and develop health and wellbeing through offering advice and guidance.
Develop an in-depth knowledge of the local health andcare infrastructure and know how and when to enable people to access supportand services that are right for them.
Use tools to measure peoples levels of knowledge,skills and confidence in managing their health and to tailor support to themaccordingly.
Support people to develop and implement personalisedcare and support plans.
Review and update personalised care and support plansat regular intervals.
Ensure personalised care and support plans arecommunicated to the GP and any other professionals involved in the personscare and uploaded to the relevant online care records, with activity recordedusing the relevantSNOMED codes.
Coordinate and integrate care
Making and managing appointments for patients, relatedto primary, secondary, community, local authority, statutory, and voluntaryorganisations
Refer onwards to social prescribing link workers andhealth and wellbeing coaches where required.
Regularly liaise with the range of multidisciplinaryprofessionals and colleagues involved in the persons care, facilitating acoordinated approach and ensuring everyone is kept up to date so that anyissues or concerns can be appropriately addressed and supported.
Actively participate in multidisciplinary team meetingsin the PCN as and when appropriate.
Identify when action or additional support is needed,alerting a named clinical contact in addition to relevant professionals, andhighlighting any safety concerns.
Record what interventions are used to support people,and how people are developing on their health and care journey,
Keep accurate and up-to-date records of contacts,appropriately using GP and other records systems relevant to the role, adheringto information governance and data protection legislation.
Work sensitively with people, their families and carersto capture key information, while tracking of the impact of care coordinationon their health and wellbeing.
Encourage people, their families and carers to providefeedback and to share their stories about the impact of care coordination ontheir lives.
Record and collate information according to agreedprotocols and contribute to evaluation reports required for the monitoring andquality improvement of the service.
Establish strong working relationships with GPs andpractice teams and work collaboratively with other care coordinators, socialprescribing link workers and health and wellbeing coaches, supporting eachother, respecting each others views and meeting regularly as a team.
Act as a champion for personalised care and shareddecision making within the practice.
Demonstrate a flexible attitude and be prepared tocarry out other duties as may be reasonably required from time to time withinthe general character of the post or the level of responsibility of the role,ensuring that work is delivered in a timely and effective manner.
Identify opportunities and gaps in the service andprovide feedback to continually improve the service and contribute to business planning.
Contribute to the development of policies and plansrelating to equality, diversity and reduction of health inequalities.
Work in accordance with the practices policies and procedures.
Contribute to the wider aims and objectives of the practiceand our PCN to improve and support primary care.
Person Specification
Additional Requirements
* ECDL or equivalent IT skill & knowledge
* Understanding of, and commitment to, equality, diversity and inclusion.
* Strong organisational skills, including planning, prioritising, time management and record keeping.
* Ability to recognise and work within limits of competence and seek advice when needed.
* Meets DBS reference standards and criminal record checks.
* Willingness to work flexible hours when required to meet work demands.
* 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.
* Knowledge of how the NHS works, including primary care and PCNs.
* Knowledge of Safeguarding Children and Vulnerable Adults policies and processes.
* Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social.
Qualifications
* GCSE Grade A to C in English Maths
* GCSE Grade A to C in Biology
* Qualified to NVQ level 2 in Health and Social Care
Experience
* Experience of data collection and using tools to measure the impact of services.
* Experience of maintaining filing systems & collating information.
* Proficient using Microsoft Word, Excel and Outlook
* Clinical System Administration
* Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement.
* 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 or training in personalised care and support planning.
* Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
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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