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Care Coordinator

5 months ago

London, United Kingdom Islington GP Federation Full time

**Job Title**:Care Coordinator

**Responsible to**:Clinical Director and PCN Operational Lead

**Place of Work**:The post holder will be required to work at various GP Practices across South Islington PCN and within different team settings, in line with the needs of the service.

**Hours**:37.5 hours per week (Monday - Friday)

**Salary**:£28,840 per annum

**Duration**:12-Month Fixed-Term with Possibility of Extension

**About Islington GP Federation**

Islington GP Federation (IGPF) is a growing organisation representing 31 practices; we have established ourselves as a leader in new ways of working, including running Islington’s extended access primary care services (I:HUB) as well as supporting the Islington Primary Care Networks (PCNs). Our current range of services include the Extended Access Service, I:HUB, Community Ear, Nose and Throat (ENT), Integrated Community Gynaecology, practice-based pharmacists and a range of practice support mechanisms.

IGPF works very closely with a range of partners including the regional commissioning group, NHS England, Healthy London Partnership, Public Health, local hospitals such as UCLH and the Whittington Health and the London Borough of Islington.

IGPF is the host organisation for the Primary Care Network (PCN) workforce and the Islington Training Hub, and has been working for over two years to create training and development programmes that meet the needs of staff working in primary and community care settings. IGPF runs two Islington GP practices on caretaking contracts; a third practice will be taken on within this financial quarter.

**Purpose of The Role**

Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

They 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 is 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, health and wellbeing coaches, and other professionals where appropriate.

Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.

**KEY RESPONSIBILITIES**
- Work with people, their families and carers to improve their understanding of their conditions and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their ‘Activation’ level.
- Support people to take up training and employment, and to access appropriate benefits where eligible.
- Provide coordination and navigation for people and their carers across health and care services, working closely with paramedics, 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.
- Identify unpaid carers and help them access services to support them;
- Conduct follow-ups on communications from out of hospital and in-patient services;
- Maintain records of referrals and interventions to enable monitoring and evaluation of the service

**KEY TASKS**

**1. Enable access to personalised care and support**
- Take referrals for individuals or proactively identify people who could benefit from support through care coordination;
- Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs;
- Support people to develop, implement and review personalised care and support plans

**2. Coordinate and integrate care**
- Help people transition seamlessly between services and support them to navigate throu