Employer: Branch End Surgery
Overall Job Purpose
A vacancy has arisen for a Care Coordinator to join our mature Primary Care Network serving the populations in Branch End Surgery.
REPORTS TO: Practice Manager/PCN Lead Care Coordinators/ PCN Manager
The opportunity is to be part of a developing team, playing an important role within the PCN to proactively identify and work with people, including the care home patients, patients with cancer, and other long-term conditions (eg Dementia, frailty, Diabetes), to provide coordination and navigation of care and support across health and care services.
You will work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This will be achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
Care coordinators review patients’ needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, and other professionals where appropriate.
The aim is to help people improve their quality of life and improve their experience across the health and care system.
The successful candidate will be based in one GP practice as part of West Northumberland PCN ( in this case Branch End Surgery) and will be expected to travel to local Care Homes locally.
They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and
learn as part of a team and committed to providing people, their families and carers with high quality support. This role is intended to become an integral part of the PCN’s multidisciplinary team, working alongside social prescribing link workers to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN. There may be a need to work remotely depending on the requirements of the role.
Please note that the role of a care coordinator is not a clinical role.
The roles that our PCN Care Coordinators will perform will vary between practices. They will depend on the needs of the GP practice that you will be attached to, as well as the PCN-led requirements. The lists of tasks and responsibilities are not restrictive or binding and are likely to develop over time.
Key responsibilities – [depending on practice requirements]
GENERIC – all Care Coordinators
· Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, ARRS staff and other primary care roles.
· Undertake accredited training as set out by The Personalised Care Institute
· Bring together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan.
· To work closely with GPs and other primary care professionals to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers;
· Manage reporting required and associated within the Direct Enhanced Service specifications and IIF targets for required services
· Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function;
· Attend regular meetings as appropriate with Lead Care Coordinators and PCN Management Team.
Other Care Coordination areas as required by the Practice
· This may include supporting patients with Frailty or other long term conditions (ie Diabetes, Dementia)
CANCER CARE – all care coordinators - Supporting and developing co-ordination and management of the Early Detection & Prevention of Cancer across the Primary Care Network and ensuring that the early part of the patient’s journey is as seamless as possible. The role may include (and will differ per practice):
· Contacting patients who are not attending cancer screening, non responders, low screening groups - help with education and advice to encourage patient to make decisions, reduce fears and offer support
· Identifying at risk populations using practice searches
· Support/ lead on signposting and advertising preventative advice
· Following up all 2 week wait referrals and ensure appointments made/attended, talk through processes
· Work with the PCN Cancer Operational Group and the Lead PCN Cancer Care Coordinator to audit safety netting procedures, support development of service and ensure DES/IIF requirements are fulfilled.
· Help patients navigate systems at a stressful time
Work with people, their families and carers to improve their understanding of the patients’ condition and support them to develop and review personalised care and support plans to manage
their needs and achieve better healthcare outcomes.
· Prepare patients for cancer care reviews/complete cancer care reviews where appropriate
ENHANCED HEALTH IN CARE HOMES (depending on practice requirements) - Providing coordination, secretarial and administration support for the Enhanced health in Care Homes (EHCH) service
· Overall responsibility for arranging Multi-Disciplinary Team (“MDT”) meetings, including the weekly Care Homes MDT meetings (virtual or face – to face), managing the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting;
· Support with identification of patients in need of review and collation of information of patients needing full MDT review.
· Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary;
· Helping residents and families focus on what matters to them, ensuring they feel care is personalised and that their voice is heard at professional meetings.
· Liaise with care home staff and patients and carers within the home when needed.
Key Tasks (depending on practices requirements as per Key Requirements)
Enable access to personalised care and support
a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination;
b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs;
c. Work towards increasing patients’ understanding of how to manage and develop health and wellbeing through offering advice and guidance;
d. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them;
e. Use tools to measure people’s levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly.
f. Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register
g. Support people to develop and implement personalised care and support plans;
h. Review and update personalised care and support plans at regular intervals;
i. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person’s care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes;
j. Where a personal health budget is an option, to work with the person and the PCN Living Well Coordinators to provide advice and support as appropriate;
Coordinate and integrate care
a. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations as needed during their journey.
b. Help people transition seamlessly between secondary and community care
services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system;
c. Refer onwards to social prescribing link workers and other professionals where required;
d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the person’s care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;
e. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate;
f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
g. Record what interventions are used to support people, and how people are developing on their health and care journey,
Professional Development
a. Work with a named clinical point of contact for advice and support.
b. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required;
c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Miscellaneous
a. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers, supporting each other, respecting each other’s views and meeting regularly as a team
b. Act as a champion for personalised care and shared decision making within the PCN
c. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner
d. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning
e. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities
f. Work in accordance with the practices’ and employers/PCN’s policies and procedures
g. Contribute to the wider aims and objectives of the PCN to improve and support primary care.
GENERIC RESPONSIBILITIES
All staff have a duty to conform to the following:
Equality, Diversity & Inclusion (ED&I)
A good attitude and positive action towards ED&I creates 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.
Everyone has the right to be treated fairly and 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.
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 others with dignity and respect.
Safety, Health, Environment and Fire (SHEF)
This PCN is committed to supporting and promoting opportunities to 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 PCN is committed to maintaining an outstanding confidential service. Patients and colleagues 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 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 and colleagues 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 PCN to look for opportunities to improve quality and share good practice.
This PCN continually strives to improve work processes which deliver health care 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.
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 partake and complete mandatory training as directed by the training coordinator, as well as participating in the PCN training programme. You will also be required to participate in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
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 they communicate in a manner which enables the sharing of information in an appropriate manner.
Service Delivery
Staff must adhere to the information contained with PCN practice policies and regional directives, ensuring protocols are adhered to at all times.
Security
The security of the PCN is the responsibility of all personnel. Staff must ensure they remain vigilant at all times and report any suspicious activity immediately to their line manager.
Pay: £14.06 per hour
Benefits:
- Free flu jabs
- Free parking
- On-site parking
Experience:
- providing care: 1 year (required)
Licence/Certification:
- Driving Licence (preferred)
Work Location: In person
