Job Summary:
The North Riding Primary Care Network are seeking to recruit a care coordinator specialising in support and co-ordination of care for patients registered with a learning disability. The role will be part of the Multi-Disciplinary Team (MDT) within the PCN and will contribute to tackling inequalities in health and social care.
The Care Co-ordinator will be a key team member who will be patient centric and contribute to ensuring equitable access to health care. They will carry out a holistic needs assessment for each patient living with a learning disability through listening, identifying, and agreeing a comprehensive personalised plan centred around what matters to the patient in order to live well in the community and improve their health and wellbeing.
They will be a key contact to identify and address issues, to signpost and link patients and carers to services in the community that will help with health and wellbeing, self-care, wider family support and to facilitate independence where appropriate. This role has a strong focus on improving significant health inequalities, improving people's quality of life, and preventing premature deaths for those with a learning disability.
The Care Co-ordinator will actively be involved in providing direct and indirect care for patients in support of the PCN multidisciplinary team and will be expected to work under direct or indirect supervision from the clinical director and PCN management team. The role will provide a single point of contact for the patients, carers and families and will be expected to work autonomously to provide this service.
All PCN Care Co-ordinators will support member practices in co-ordinating all key activity including access to services, advice and information ensuring all health and care planning is timely, efficient, and patient centred. They will also work alongside social prescribing link workers, mental health workers and other professionals to provide an all-encompassing approach to personalised care and enable people to navigate through the health and care system.
North Riding Primary Care Network was founded in 2019 and has four member practices. We are located on the edge of the North York Moors National Park and our member practices are Ayton and Snainton Medical Practice, Ampleforth and Hovingham Surgeries, Derwent Practice and Sherburn and Rillington Medical Practice. We provide care to an overall patient population of 39,000. Each member practice has a CQC rating of good in all areas and 3 out of the 4 practices are rural dispensing practices. Our aim is to deliver high quality services for our patients, facilitated by working collaboratively, to better respond to the needs of our local population. We are building a multi-disciplinary clinical team to support our practices and offer new services to our patients. If you are interested in joining our team we would love to hear from you.
PRIMARY DUTIES AND AREAS OF RESPONSIBILITY
· Work within member practices to help deliver outcomes defined within the enhanced service and any additional appropriate quality improvement schemes set by the PCN
· Carry out annual LD health checks, feeding back to each practice on outcomes and liaising with colleagues as appropriate.
· To collate all a patient's identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice.
· To act as a point of contact for neurodiverse individuals and their families, guiding them through available services and resources.
· Support patients and carers to utilise decision aids in preparation for a shared decision-making conversation, utilising any available decision support tools.
· Promote the importance of the uptake of health checks, screening and vaccination programmes taking into consideration any reasonable adjustments needed.
· Where necessary to take blood and blood pressure readings (appropriate training can be given if required).
· To support patients in managing their needs through answering queries, making appointments, and ensuring access to high quality and easy to understand information.
· Provide co-ordination and navigation for patients and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals.
· Build relationships with community organisations, schools, and service providers to expand access to resources and opportunities locally for neurodiverse individuals.
· Support patients to take up training opportunities that may assist with employment, or provide support in enabling them, where eligible, to access appropriate benefits or personal health budgets.
· Utilise Population and Clinical Reporting within the clinical system to help identify target patient populations.
· Record patient interventions on relevant electronic database systems (e.g., SystmOne) and contribute to report generation, analysis, and production
· Raise and discuss patient related concerns following safeguarding procedures for the PCN.
· Ensure colleagues are made aware of any service changes, offering guidance and help as required
· Advocate for LD patients and neurodiverse individuals' needs within the healthcare system.
PERSONAL SPECIFICATION
Qualifications and Training:
Essential:
- Educated to NVQ Level 3 or equivalent (e.g., 2 A – Levels) or evidence of strong relevant experience
Desirable:
- Bachelor's degree in Social Work, Psychology, Nursing, Education or a related field.
- Minimum of 2 years’ experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field
- Experience/Qualification in Autism, ADHD, or other neurodiversity related areas are advantageous.
Knowledge and evidence of:
Essential:
- Understanding of working with confidential information and an understanding of service user confidentiality
- Previous experience working with people and carers of individuals with a Learning Disability and or Neurodiversity.
- Ability to communicate confidently with staff of all seniority levels
Desirable:
- Understanding of basic health and social care terminology
- Working in a multi-disciplinary setting
- Understanding of the current issues facing the NHS
- Knowledge of social service structures
- Understanding of health and social care processes
- Developing relationships with a wide variety of people
- Health and social care assessments
- Ability to deliver successful outcomes within determined timeframes
- Continuous CPD and identifying opportunities for self-development
Skills and abilities:
Essential:
- Excellent communication skills, verbal and non verbal
- IT skills, including accurate written/electronic records and documents
- Recording and collection of data and to support clinical care and to inform decision making
- Prioritise own workload and meet required timescales
- Identify need for service development and implementation of action plans to address
- Convey sensitive information in an empathetic manner to patients/clients/client’s relatives/carers and staff
- Negotiation and conflict resolution skills
- Full clean UK drivers’ licence
Please submit your CV along with a covering letter to demonstrate how you can meet the criteria in the job description and personal specification above.
Holiday entitlement: 25 days (pro rata) + Bank holidays
Pay: £25,740.00-£27,690.00 per year
Benefits:
Work Location: In person
