Care Co-ordinator

4 months ago

Bury, United Kingdom Bury GP Federation Full time

Job Title: Care Co-ordinator (Personalised Care) - Horizon PCN

Contract Term: Permanent

Salary £23,949.00 - £26,282.00

Hours: 37.5 hrs Monday - Friday

Responsible to: PCN Development Manager - Horizon PCN

Accountable to: PCN Clinical Director

**Job Summary**

We are expanding our PCN team and have an exciting opportunity for two Personalised Care Care Co-ordinators to provide timely, accurate information and effective support to our new Personalised Care team and the patients it supports. The team will provide practical facilitation and interventions to promote patient activation and self-management and improve wider health outcomes and patient well-being. The Care Co-ordinators will work in conjunction with a multi-disciplinary team of professionals across the health and social care system to assess needs and identify and agree person-centred outcomes to improve quality of life.

**Responsibilities**:

- Utilise population health intelligence to proactively identify and work with defined cohort(s) of patients to deliver personalised care
- Work with the GPs, Public Health and other primary care professionals within the Primary Care Network to identify and manage cohorts of patients, and where required and as appropriate, refer people back to other health professionals within the PCN
- Support patients to utilise decision aids in preparation for a shared decision-making conversation
- Holistically bring together all a person’s identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the individual
- Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care
- Support people to take up training and employment, and to access appropriate benefits where eligible
- Support people to take up health checks, flu vaccinations and other primary care services
- Support people to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure
- Explore and assist people to access personal health budgets where appropriate
- Provide co-ordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and well-being coaches, and other primary care professionals
- Support the co-ordination and delivery of Multi-Disciplinary Teams within the PCN for this client group
- Raise awareness within the PCN of shared decision making and decision support tools
- Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.
- Ensure that organisations and groups to whom patients are directed have basic safeguarding processes in place for vulnerable individuals; and provide opportunities for the patient to develop friendships and a sense of belonging, as well as to build knowledge, skills and confidence.
- Raise and discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with management and if appropriate GPs
- Report regularly to the PCN Board and/or Management Team on key indicators, including take up of flu vaccinations, health screening, long term condition surveillance, having a PSCP in place and reviewed.
- Liaise closely with each GP practice within the PCN to understand the specific needs and issues and ensure the service is tailored accordingly, adding value

**Person Specification**

**Experience**

**Essential**
- Experience of collaborative working and building relationships across varied organisations
- Ability to work independently and within a team

**Desirable**
- Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement

**Skills**

**Essential**
- Good experience of IT systems and packages, data collection and providing monitoring information and proficient in the use of Microsoft Office
- Ability to follow policies, procedures, and care pathways
- Excellent communication and listening skills including ability to communicate effectively, both verbally and in writing, with a wide range of people and stakeholders
- Excellent administration and record keeping skills including ability to prioritise and finish tasks

**Qualifications**

**Essential**
- Good Standard of Education

**Knowledge**

**Desirable**
- Knowledge of chronic disease/long-term conditions and population/public health in a Primary Care context

**Salary**: £23,949.00-£26,282.00 per year

**Benefits**:

- Employee discount
- Gym membership

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