Care Coordinator

Job summary We have an excitingopportunity for enthusiastic Care Coordinators to join our dynamic team.
This position is well suited to individuals who care aboutproviding high quality, responsive care in a community setting.
The role ispart of the PACTeam (Proactive Care Team), who sit within Primary Care.
Primarycare work experience would be beneficial, but not essential.
The PACTeam carryout proactive and reactive visits for our housebound patients who are frail,require Long Term Conditions ( Asthma/Diabetes/ CHD etc) reviews, Learning Disability and Serious MentalIllness reviews.
Itis more important that you have the right transferrable skills and experience,are an excellent communicator and have a flexible approach.
If you areresilient, calm under pressure and enjoy a team approach supported by a growingmultidisciplinary team, then we cant wait to hear from you.
A specialist interest and expertise in LongTerm Condition (LTC) Assessments is desiredbut not essential.
Main duties of the job Performingcomprehensive geriatric assessments (CGA) on a cohort of patients with moderate/ severe frailty identified with a risk stratification tool, or through otherreferral routes into PACT (eg, virtual ward discharges).Workingwith other members of the PACT MDT to plan and visit patients on a proactive orreactive need, working in patients own homes and care settings.Workingwith the PACT MDT on Enhanced Health in Care homes, anticipatory care planningand supporting personalised care planning.Advisepatients on maintaining health and refer to allied services when a healthpromotion need is identified.Communicateat all levels within the multidisciplinary team ensuring an effective serviceis delivered.Maintainaccurate, contemporaneous healthcare records appropriate to the consultationEnsureevidenced-based care is delivered at the highest standards ensuring delivery ofhigh-quality patient careContributeto the weekly PACT MDT, presenting patients for discussion/feedback.Workingwith the PACT MDT, PCN practices and wider Community Partnership to identifypatients appropriate for the proactive care team model.Therole will also cover reviews for different cohorts of patients, includinglearning disabilities and mental health illness reviews and Long-Term ConditionReviews.This role is constantly developing and new functionsare being developed with appropriate training and support.
About us Our team consists of some dynamicand forward thinking professionals who have embraced the Additional Roles Reimbursementroles with us developing a PACT MDT that integrates:Care-coordinationand assessment (Health Care Assistants).Physiotherapy.OccupationalHealthPracticebased Advanced Nurse Practitionerss and GPs.CareTrust based Community Matron and District Nurse lead.SocialPrescribers supported by our Self-Care Champion.Pharmacist support.MentalHealth PractitionersAllsupported by our PCN managerConsiderablepeer support available, and regular Clinical meetings through the network of Practicesyou will be working with.
There are additional benefits to working for ourPrimary Care Network team:AutoEnrolment to the NHS Pension Scheme or an alternative government-based scheme(based on eligibility).Attractivesalaries (dependent on experience and qualifications)Accessto NHS IT systems.Annualleave entitlement.OnAppointment 27 days plus 8 days bank holiday entitlement.PCNSocial events / Nights out.Programmeof mandatory trainingBeyondthe Pro Active work, our PACT team has also been agile in supporting the catchup in learning disability and serious mental illness reviews.
We would alsolike the successful candidate to have a special interest and expertise incompleting long term condition support and reviews for patients who struggle toaccess practice based offers.
Job description Job responsibilities The proactive care team (PACT) is a weekday service and the role involves:Performing comprehensive geriatric assessments (CGA) on a cohort of patients with moderate / severe frailty identified with a risk stratification tool, or through other referral routes into PACT (eg, virtual ward discharges).
Using the CGA template to perform the assessment and document on the clinical reporting system.
The assessment will be carried out by the Care coordinator with support and supervision from the wider PACT MDT as needed.
Working with other members of the PACT MDT to plan and visit patients on a proactive or reactive need, working in patients own homes and care settings.
Working with the PACT MDT on Enhanced Health in Care homes, anticipatory care planning and supporting personalised care planning.
Advise patients on maintaining health and refer to allied services when a health promotion need is identified.
Communicate at all levels within the multidisciplinary team ensuring an effective service is delivered.
Maintain accurate, contemporaneous healthcare records appropriate to the consultation Ensure evidenced-based care is delivered at the highest standards ensuring delivery of high-quality patient care Contribute to the weekly PACT MDT, presenting patients for discussion/feedback Working with the PACT MDT, PCN practices and wider Community Partnership to identify patients appropriate for the proactive care team model.
The role will also cover reviews for different cohorts of patients, including learning disabilities and mental health illness reviews and Long-Term Condition Reviews.This role is constantly developing and new functions are being developed with appropriate training and support.Working as part of a TeamSupport the flexible delivery and development of the proactive care model within the Five Lane Ends PCN.
Work in collaboration with other members of the PACT MDT to deliver safe effective service Contribute to the wider MDT discussions as part of the feedback process under the proactive care model Undertake independent assessments and summarise information to feed back to the MDT Ability to recognise your own limitations and escalate cases to senior colleagues as appropriateManaging SelfManaging your own diary and patient visits Participate annually identifying, developing and agreeing your own development plan with your line manager using the Appraisal process.
Participate in regular supervision.
Attend all mandatory training.
Comply with all local and national policies, procedures and protocols.
Pay regard to materials and equipment.
Carry out duties with due regard to the Equal Opportunity Policy.
Seek advice and support from your line manager whenever necessary.
Ability to work independently and manage workload supported by PACT MDT memberStaff Supervision and SupportRecognise the need for and provide on-site clinical learning opportunities for junior colleagues, care home staff etc.Financial ResponsibilityNo financial responsibility.SafeguardingAll staff members have a duty to report any concerns they have about the safety or well being of adult service users, members of their families, including children.
Employees should be aware of their roles & responsibilities to both prevent and respond appropriately to abuse.
They should undertake the safeguarding training required for their particular role.Infection ControlAll clinical and non-clinical staff are responsible for infection control.This requires you to:Maintain infection prevention and control procedures and policies for yourself and others.
Be familiar with and comply with current infection prevention and control, guidelines, policies and procedures.
Raise matters of non-compliance with your manager.
Attend infection prevention and control mandatory training as dictated by your manager.
Be appraised in relation to infection prevention and control.Risk ManagementAll staff need a basic working knowledge of risk management.
They all have a responsibility to identify and report risks, hazards, incidents, accidents and near misses promptly, in accordance with Policy.
All staff must be familiar with emergency procedures, risk management systems and incident management in their workplace.Health and SafetyAll employees have a responsibility under the Health and Safety at Work Etc Act 1974 for their own health, safety and welfare and to ensure that the agreed safety procedures are carried out to provide a safe environment for other employees and anyone else that may be affected by the carrying out of their duties.Employees must co-operate in meeting their statutory obligations with regard to health and safety legislation and must report any accidents, incidents and problems as soon as practicable to their immediate supervisor.Information ManagementAll members of staff are bound by the requirements of the Data Protection Act 1998 and any breaches of the Act or of the confidential nature of the work of this post could lead to dismissal.The post holder is responsible to learn about information governance, to help ensure that best practice guidelines are followed and personal information is managed to benefit patients, clients and members of staff.The post holder is required to sign the declaration form to confirm they have read and understood the booklet and leaflet regarding information governance, which will be kept by the HR team in the post holders personnel file.
Person Specification Education Essential Qualifications Essential Educated to GCSE level or equivalent Desirable Active signposting or care navigation or care coordination training qualification Customer service qualification (NVQ) or equivalent Experience Essential Experience of working in primary care Experience of working in a GP practice Qualifications Essential Willingness to undertake appropriate training required for role.
It is essential applicants are IT literate with working knowledge of Microsoft Office Applications.
Applicants must be able to work on own initiative and under pressure, prioritise workload and function as a team member.
The ability to work flexible is essential.
Desirable LTC knowledge and specialism