Care Coordinator

Job description

Job responsibilities

Key Responsibilities

Work with patients, their families and carers in order 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

Help patients to manage their needs through answering queries, making and managing appointments, and ensuring the patients have good quality written or verbal information to help them make choices about their care

Support patients to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing

Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing

Support patients who take up training and employment, and to access appropriate benefits where eligible

Provide coordination 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; helping to ensure patients receive a joined up service and the most appropriate support

Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN

Support the coordination and delivery of multidisciplinary teams with the PCN

Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients and to be more prepared to have shared decision making conversations

Explore and assist patients to access a personal health budget where appropriate

Key Tasks

1. Enable access to personalised care and support

a. Take referrals for individuals or proactively identify patients who could benefit from support through care coordination

b. Have a positive, empathetic and responsive conversation with the patient and their family and carer(s) about their needs

c. Support patients to develop and implement personalised care and support plans

d. Review and update personalised care and support plans at regular intervals

e. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patients care and uploaded to the relevant online care records, with activity recorded using the relevant codes

f. Where a personal health budget is an option, to work with the patient and the local ICB to provide advice and support as appropriate

2. Coordinate and integrate care

a. Help patients transition seamlessly between services and support them to navigate through the health and care system

b. Refer onwards to social prescribing link workers and health and wellbeing coaches where required

c. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the patients 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

d. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate

e. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns

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 & Barring Service (formerly CRB) to check for any previous criminal convictions.

Communication

The post holder should recognise the importance of effective communication within the team and will strive to:

Communicate effectively with other team members

Communicate effectively with patients and carers

Recognise peoples needs for alternative methods of communication and respond accordingly

Confidentiality

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data

Qualities

The post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

Health & Safety

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety policy, the Health & Safety manual, and the Practice Infection Control policy and published procedures. This will include:

Using personal security systems within the workplace according to practice guidelines

Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks

Making effective use of training to update knowledge and skills

Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards

Actively reporting of health and safety hazards and infection hazards immediately when recognised

Keeping own work areas and general/patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the post-holders role

Undertaking periodic infection control training (minimum annually)

Reporting potential risks identified

Demonstrate due regard for safeguarding and promoting the welfare of children

Equality & Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with Practice procedures and policies and current legislation

Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues

Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights

This job description is a reflection of the current position and may change in emphasis or detail in the light of subsequent development, in consultation with the post holder.

Person Specification

Personal Attributes

Essential

• Ability to actively listen, empathise and provide personalised support in a non-judgemental way, to inspire trust and confidence and motivate people to reach their potential
• Ability to provide a culturally sensitive service, supporting people from all background and communities, respecting lifestyle and diversity
• Commitment to reducing health inequalities and proactively working with to reach people from diverse communities
• High level of written and verbal communication skills and the ability to communicate effectively both verbally and in writing, with people, their families, carers and other stakeholders.
• Ability to identify risk and assess and manage when working with individuals
• Have a strong awareness and understanding of when it is appropriate to refer back to other health professionals/agencies
• Ability to maintain effective working relationships with all colleagues and work flexibly and enthusiastically within a team or working under own initiative
• To promote collaborative working
• Ability to demonstrate personal accountability, resilience and work well under pressure
• Ability to organise, plan and prioritise under own initiative and when under pressure and meeting deadlines
• Knowledge of, and ability to work to, policies and procedures including confidentiality, safeguarding, information governance and health and safety

Qualifications

Essential

• Experience of working within healthcare
• Registered General Nurse (degree level)
• Commitment to professional development
• Experience of working with multi-professional team environment
• Experience of dealing with public/patients
• Experience of supporting people, their families or carers in a related role
• Experience of working in accordance with the UKCC Code of Practice
• Experience of data collection and using audits to measure the impact of services
• Demonstrable commitment to professional and personal development
• Ability to use Microsoft Office applications
• Experience or training in personalised are and support
• Experience in Chronic Disease Management
• Current emergency resuscitation training certificate
• Experience of EMIS Web clinical system
• Experience of Docman10
• Experience of infection prevention and control measures

Knowledge & Skills

Essential

• Strong organisational skills including planning, prioritising, time management and record keeping
• Strong IT skills to include EMIS, Docman, Word, Excel and experience of using databases
• Ability to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients, including GPs, Practice Nurses, healthcare professionals and other staff
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding the needs of older people/adults with disabilities/long-term conditions particularly in relation to promoting independence
• Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social
• Ability to recognise and work within limits of competence and seek advice when needed
• Willing to travel across PCN sites if/when required
• Familiar with local resources and services and how to access them
• Knowledge of the NHS works, including PCNs
• Knowledge of safeguarding policies and processes
• Ability to record accurate clinical notes
• Ability to work within own scope of practice and understand when to refer to GP
• Broad knowledge of clinical governance
• Understanding the importance of evidence-based practice

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.

Employer details

Employer name

St Georges Medical Centre

Address

55 St Georges Avenue

Sheerness

Kent

ME12 1QU

Employer's website

https://www.saintgeorgesmedicalcentre.co.uk/ (Opens in a new tab)