The Care Coordinator (CC) may be required to deal with patients and, if appropriate, their carers, before or after the patient’s consultation with a clinician or other healthcare professional.
The CC’s role requires them to be able to work closely with the patient and their clinician or other healthcare professional and understand the roles of, a variety of different people working in the practice and across the PCN.
The CC will be involved in coordinating patients’ healthcare and directing them to the appropriate service to ensure that they get the most suitable care from whatever health or social care provider is appropriate
You may be given a caseload of identified patients and be required to ensure that their changing or present needs are addressed by taking into account local priorities, health inequalities and/or population health management risk stratification.
- Showing courtesy
- Seeking to understand
- Treating all fairly
- Valuing each person as a unique individual
- Being especially supportive to the vulnerable
Working as a team
- Relating well within the team
- Valuing the contribution of each team member
- Building a mutually supportive environment
- Co-operating with other teams
- Encouraging responsible involvement by our patients
Integrity
- Speaking and acting truthfully
- Being accountable for our actions
Learning and improving
- Adapting to change
- Building on achievements
- Developing our services
Equality, Diversity & Inclusion
A good attitude and positive action towards Equality Diversity and Inclusion (EDI) create an environment where all individuals are able to achieve their full potential. Creating such an environment is important for three reasons: it improves operational effectiveness, it is morally the right thing to do, and it is required by law.
Patients and their families have the right to be treated fairly and to be routinely involved in decisions about their treatment and care. They can expect to be treated with dignity and respect and will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Patients have a responsibility to treat other patients and our staff with dignity and respect.
Staff have the right to be treated fairly in recruitment and career progression. Staff can expect to work in an environment where diversity is valued, and equality of opportunity is promoted. Staff will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Staff have a responsibility to ensure that they treat our patients and their colleagues with dignity and respect.
Safety, Health, Environment and Fire (SHEF)
This practice is committed to supporting and promoting opportunities for staff to maintain their health, well-being and safety. You have a duty to take reasonable care of health and safety at work for you, your team and others, and to cooperate with employers to ensure compliance with health and safety requirements. All personnel are to comply with the Health and Safety at Work Act 1974, Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.
Confidentiality
This practice is committed to maintaining an outstanding confidential service. Patients entrust and permit us to collect and retain sensitive information relating to their health and other matters pertaining to their care. They do so in confidence and have a right to expect that all staff will respect their privacy and maintain confidentiality at all times. It is essential that if the legal requirements are to be met and the trust of our patients is to be retained that all staff protect patient information and provide a confidential service.
Quality & Continuous Improvement (CI)
To preserve and improve the quality of our output, all personnel are required to think not only of what they do but how they achieve it. By continually re-examining our processes, we will be able to develop and improve the overall effectiveness of the way we work. The responsibility for this rests with everyone working within the practice to look for opportunities to improve quality and share good practice.
This practice continually strives to improve work processes which deliver healthcare with improved results across all areas of our service provision. We promote a culture of continuous improvement, where everyone counts and staff are permitted to make suggestions and contributions to improve our service delivery and enhance patient care.
Induction training
On arrival at the practice, all personnel are to complete a practice induction programme.
Learning and development
The effective use of training and development is fundamental in ensuring that all staff are equipped with the appropriate skills, knowledge, attitude and competences to perform their role. All staff will be required to participate in and complete mandatory training, as directed by the training coordinator, as well as participating in the practice’s training programme. Staff will also be permitted (subject to approval) to undertake external training courses which will enhance their knowledge and skills, progress their career and, ultimately, enable them to improve processes and service delivery.
Collaborative working
All staff are to recognise the significance of collaborative working. Teamwork is essential in multidisciplinary environments. Effective communication is essential, and all staff must ensure that they communicate in a manner which enables the sharing of information in an appropriate manner.
Service delivery
Staff at DMC must adhere to the information contained within practice policies and regional directives, ensuring that protocols are adhered to at all times. Staff will be given detailed information during the induction process regarding policy and procedure.
Security
The security of the practice is the responsibility of all personnel. Staff must ensure that they remain vigilant at all times and report any suspicious activity immediately to their line manager. Under no circumstances are staff to share the codes for the door locks with anyone and they are to ensure that restricted areas remain effectively secured.
Professional conduct
At DMC staff are required to dress appropriately for their role.
Leave
All personnel are entitled to take leave. Line managers are to ensure that all of their staff are afforded the opportunity to take leave each year and should be encouraged to take all of their leave entitlement.
Location
This role is split across two practice sites:
- Chadwick Road Surgery
- Crystal Palace Road Surgery
Core functions, but not limited to:
The following are the core responsibilities of the care coordinator. There may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:
- Support Quality and Outcome Frameworks, PCN and other LES and DES specifications
- Maintain and develop engagement with appropriate DCM colleagues and encourage ‘best practice’
- Act as the first port of call for patients, in their caseload in relation to their care.
- Support and Manage clinical call and recall
- Bring together all of a person’s identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP)
- Working across DCM Primary Care to manage the needs of patients in Care Homes, supported accommodation or trying to remain living at home
- Performance targets - Ensure all patients receive enhanced care in a timely fashion and any other aspect of managing the patient facing service.
- Support with the performance/KPIs dashboards.
- Undertake audits for dashboards/KPIs
- Support with any admin related task to the central team
- To work as part of a multi-disciplinary team in a patient facing role to assess and respond to patients and colleagues using their expert knowledge
- To be responsible for arranging assessment of new patients with subsequent production and completion of individual care plans by appropriate clinicians
- To provide personalised support to individuals, their families and carers to ensure that they are active participants in their own healthcare and to empower them to take more control in managing their own health and well-being, to live independently and to improve their health outcomes Undertake work in line with PCN directed priorities.
- Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids
- Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance
- Support national screening and immunisation programmes and health checks/screening
- Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact
- Direct liaison with multiple agencies to coordinate care for patients
- Refer to social prescribing link workers or health coaches were a patient is identified as potentially benefitting from this service
- To support patient/carer contact roles, and collate patient and carer feedback on their experiences
- Raise awareness of shared decision-making and decision support tools, and assist people to be more prepared to have a shared decision-making conversation
- 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 – their “Activation “level – when engaging with their health and wellbeing, including using 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 and other primary care roles.
- Support the coordination and delivery of MDTs for their patient cohort
Administrative duties (additional where required)
- To process registering new patients, making up notes and entering their details on the computer system.
- To process new arrivals and deductions.
- To support with GP Links.
- Management of the generic inbox
- Scanning and coding all clinical documents.
- Using the electronic filing system to complete filing.
- Dealing with internal and external post
- To complete admin tasks and support with AccuRx Total Triage
- To undertake photo-copying and other basic office duties as directed by members of the team.
- To deal with queries for further information from hospitals or other local providers about patients.
- To assist in preparing and sending out practice correspondence.
- Ensure that the system is operational at the beginning of each day & switched on to the answer phone with the correct tape at lunchtime & at the end of each day.
- Clerical Duties
- Ensure that prescriptions are handled accurately and efficiently following protocol
- Monitor incoming electronic test results to ensure prompt review by clinicians
- Data entry of new and temporary registrations and relevant patient information e.g. smoking status, BP, ethnicity, medication from hospital letters
- Scan all patient information in computerised record i.e. medical documents, hospital reports and letters as necessary
- Deal with referrals to primary and secondary care
- Action tasks set by clinicians via the clinical systems and email
- Handling of document via clinical systems and practice protocols
Secondary responsibilities
In addition to the primary responsibilities, the Care Coordinator may be requested to:
- Participate in practice audit as directed by the audit lead
- To be flexible to cover shifts in the event of staff holidays and sickness.
- Provide lunch cover where needed.
- To undertake any other duties required by the needs of the practice & commensurate with the post.
- Following mandatory training - to act as a chaperone when required. To participate and contribute to team meetings and other meetings as required.
- To undertake training as required including mandatory and statutory training, core skills training and ongoing developmental training.
- To have knowledge of all Practice procedures.
- To work in accordance of written protocols.
- To participate in appraisal scheme.
- To present a positive image of the practice at all times.
Qualifications
- The Care Coordinator is enrolled in, undertaking or qualified in appropriate training as set out by the personalised care framework
- Passed training requirements as outlined by the Personalised Care Institute and fully understands the personalised care framework
Experience
-
Experience of working in a primary care setting
Skills
- Excellent communication skills (written and oral)
- A clear understanding of child protection policy and procedures and commitment to the safeguarding of children and vulnerable adults
- Experience in use of the Patient Activation Measure (PAM)
- Good IT skills
- Clear, polite telephone manner
- Good knowledge of MS Office and Outlook
- EMIS/SystmOne/Vision user skills
- Effective time management (planning and organising)
- Ability to listen, empathise with people and provide person centred support in a non-judgemental way
- Courteous, respectful and helpful at all times
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from all communities
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to use own initiative, discretion and sensitivity
- Ability to work as a team member and autonomously
- Good interpersonal skills
- Problem solving and analytical skills
- Ability to follow policy and procedure
Personal qualities
- Polite and confident
- Flexible and cooperative
- Motivated
- Forward thinker
- High levels of integrity and loyalty
- Sensitive and empathetic in distressing situations
- Ability to work under pressure
Other requirements
- Flexibility to work outside of core office hours
- Disclosure Barring Service (DBS) check
- Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own home
DMC Healthcare is a leading independent provider of primary care, consultant-led dermatology, radiology reporting, in-sourced routine endoscopy services and MSK community services to the NHS.
We believe that everyone should have the opportunity to achieve healthier outcomes.
Firmly rooted in the NHS and dedicated to excellent patient care for nearly 55 years, DMC Healthcare currently works with 30+ NHS organisations and other partners, treating over 100,000* patients each year.
With NHS waiting list pressures, workforce shortages and unprecedented demand, we want to help. We support capacity deficits with a firm eye on quality and robust clinical governance.
Find out more: https://dmchealthcare.co.uk
