Patient Care Coordinator

Position Overview

The Patient Care Coordination team is tasked with overseeing the management and organization of care for individuals with learning disabilities, mental health issues, physical health concerns, and complex needs. The needs of patients are assessed and regularly monitored in accordance with national standards for individuals eligible for NHS Continuing Healthcare (CHC), operating within the Shropshire, Telford and Wrekin Integrated Care Board. As a Patient Care Coordinator, a qualification as a registered nurse or social worker is essential.

Required Qualifications

A current registration with the NMC or HCPC is mandatory, along with the capability to travel within the designated area, which may occasionally include travel beyond county lines.

A solid understanding of the National Framework for NHS Continuing Healthcare and Funded Nursing Care is expected, particularly regarding patient evaluations. Familiarity with the Mental Health Act, especially concerning s117 eligibility, is advantageous, as is experience with the Mental Capacity Act, Best Interest decision-making, Deprivation of Liberty Safeguards (DOLS), and Court of Protection matters.

While experience as a CHC assessor and commissioner is preferred, candidates with a background in case management without CHC experience are also encouraged to apply.

Key Responsibilities

We seek an individual with expertise in patient assessment, experience in collaborating with multidisciplinary teams, and knowledge of or experience in care delivery. You will evaluate care requirements and guide individuals towards the most suitable care options to address their identified needs. As a Patient Care Coordinator, you will have the opportunity to positively impact the lives of those you assist, ensuring quality assurance and financial agreements that provide value for both the NHS and the patient. You will have access to learning and development opportunities to enhance your clinical knowledge of complex care and conditions, as well as key skills in communication and collaboration with various professional and service provider teams. Participation in national and local forums will allow you to contribute to the evolution of NHS services. You will cultivate essential leadership and organizational skills while developing IT and digital competencies using existing care recording systems.

About Our Organization

NHS Shropshire, Telford and Wrekin was established to oversee the planning and procurement of a comprehensive range of health and care services for the Shropshire, Telford and Wrekin area. This encompasses GP and primary care services, hospital care, community healthcare, and mental health services. We are committed to monitoring these services to ensure they deliver high-quality care and represent good value for money. Our organization is clinically led and collaborates closely with numerous GP practices throughout the region, enabling us to forge stronger connections with our patients and develop more tailored local health services.

In return, we offer a supportive environment conducive to learning and professional growth, with opportunities to advance your skills and career in a dynamic and evolving setting. Joining our inclusive and innovative team comes with a variety of benefits, including flexible working arrangements, a pension scheme, and a generous annual leave allowance. Our training programs and support networks empower you to take a leading role in the future of healthcare, regardless of your specialty or interests. Additionally, as a member of NHS staff, you will enjoy numerous discounts.

Job Duties

The successful candidate will be accountable to the Head of All Age Continuing Care and Individual Commissioning and will report to the Case Management Team Manager, receiving support from a Team Leader.

The role requires working across various specialties based on competency levels. For instance, all team members will be expected to manage Personal Health Budgets (PHB) or appeals, but only those qualified will handle cases involving children or Learning Disabilities (LD).

The Patient Care Coordinator will play an active role as an expert clinician, facilitating and providing professional support, commissioning, and managing cases for patients eligible for NHS Continuing Care, NHS Funded Nursing Care, and those receiving joint or integrated funding, including patients subject to various sections of the Mental Health Act. This includes individuals with complex physical, mental health, and learning disability needs.

The coordinator will manage a designated caseload, ensuring that the health and care needs of patients are met and regularly reviewed in accordance with local and national standards, while also conducting eligibility assessments as necessary.

The role includes providing formal and informal training as required, and the candidate should possess in-depth knowledge of the relevant policies and procedures associated with the role.

Key Working Relationships

The Patient Care Coordinator will need to establish and maintain effective working relationships with various stakeholders, including but not limited to:

• Individual Commissioning management team
• Individual Commissioning team members
• Safeguarding teams
• Local Authority
• Service users and their families
• Legal representatives
• NHSE/I
• Care providers across all sectors
• NHS STW colleagues
• Educational institutions
• Finance team
• Commissioning team
• Other teams to address interdependencies and ensure alignment of objectives.

Key Duties & Responsibilities

The Patient Care Coordinator will oversee the coordination and monitoring of complex care packages and NHS-funded placements. This role necessitates close collaboration with patients and their families to ensure they understand the process and eligibility criteria, while providing empathetic support.

A flexible approach to care is essential, as the coordinator will work across inter-agency boundaries, maintaining effective communication and collaboration with all professionals and the public.

The coordinator will conduct care reviews for individuals whose care is fully or partially funded by the NHS, ensuring patient-centered support and facilitating the most appropriate and cost-effective care pathways.

The coordinator will lead the management of care packages for individuals in various care and support settings.

The job description and person specification outline the tasks, responsibilities, and outcomes required for this role. The job holder may be assigned additional duties as reasonably required by their line manager.

Operational Responsibilities

The coordinator will manage a defined caseload, undertaking responsibilities as delegated by the Team Leader/Manager, which includes the routine management of complex cases and the planning, organization, and commissioning of specialized care packages while maintaining accurate records.

The coordinator will participate in the assessment, monitoring, review, and complaints processes for individuals with varying levels of complex needs whose care is managed in their homes or care settings.

The coordinator will assist or lead in the coordination of complex care packages involving members of the multidisciplinary/multi-professional team as required.

The coordinator will support the collaboration and coordination of the review and assessment process, undertaking reviews and assessments, including formal eligibility assessments as indicated.

The coordinator will conduct needs portrayal and retrospective assessments for PUPOC and appeals.

The coordinator will practice in accordance with the NMC Code of Conduct and Guidelines or equivalent for their specialist health profession.

The coordinator will operate within a clinical governance framework that promotes quality.

The coordinator will coordinate and commission complex care packages involving members of the multidisciplinary/multi-professional team.

Financial and Resource Management Responsibilities

The coordinator will support and inform teams on resource targeting, monitoring, implementation, evaluation, and delivery of plans by providing high-quality information and analysis.

The coordinator will strive to deliver project/function/patient outcomes, ensuring value for money and greater efficiency.

The coordinator will contribute to the financial delivery of the service, ensuring it is cost-effective and delivered on time.

The coordinator will commission care to meet individual patient needs, ensuring optimal value and the least restrictive care is achieved.

The coordinator will collaborate with all care providers to negotiate packages that ensure optimal value for money and advise on market development needs.

Human Resources Responsibilities

The coordinator will provide specialized training, advice, and support regarding their role and responsibilities across NHS Shropshire, Telford and Wrekin and the broader system.

The coordinator will participate in the recruitment process for support staff.

The coordinator will be accountable for their professional development and participate in performance reviews.

The coordinator will attend relevant training and staff meetings as required, including participation in nursing and clinical development across NHS Shropshire, Telford and Wrekin.

The coordinator will commit to undertaking clinical supervision.

Information Management Responsibilities

The coordinator will contribute to the review and development of existing information management systems and support the development of an integrated approach.

The coordinator will maintain accurate and comprehensive clinical records.

The coordinator will participate in and conduct audits, supporting the implementation of recommended actions.

The coordinator will gather, maintain, and analyze information to predict and meet future organizational and team needs by identifying best professional practices.

The coordinator will conduct timely and accurate information analysis and reporting on agreed areas of responsibility.

The coordinator will actively support and contribute to the development of key performance indicators for the successful assessment of performance.

Planning and Organization Responsibilities

The coordinator will plan their workload and schedule to ensure local, national, and statutory targets and deadlines are met.

The coordinator will undertake complex clinical assessments and care planning to ensure patient needs are met, and where appropriate, plan and coordinate step-down/discharge processes to meet patient needs in the least restrictive manner.

The coordinator will collaborate with team members and key stakeholders to investigate any variances from planned delivery targets and contribute to implementing solutions.

Policy and Service Development Responsibilities

The coordinator will contribute to strategic planning, recommending adjustments as necessary.

The coordinator will support the implementation of strategic modernization/service improvement, public health, workforce, or commissioning strategies and associated action plans, in line with the agreed priorities of the team.

The coordinator will contribute to the development of performance and governance strategies and the implementation of improvement programs.

The coordinator will work towards achieving quality outcomes, prioritizing their workload, and adhering to tight deadlines.

The coordinator will propose changes to their function, informing policy and making recommendations for other project deliveries.

Research and Development Responsibilities

The coordinator will be accountable for their professional development and participate in performance reviews.