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PACT Care Coordinator

2 months ago

Romford, United Kingdom Havering Health Ltd Full time

Job summary

Are you motivated with excellent organisation and communication skills? Do you have an interest in frailty?

Havering Liberty PCN is looking to appoint a Care Coordinator who has an interest in working with older housebound individuals living with frailty or complex needs to live longer and healthier lives. The post holder will be part of a brand-new team of ACPs and care-coordinators within the PCN who will be pioneering a new approach to neighbourhood integration, reaching out to, and working with, existing teams in a coordinated and purposeful way the HLPCN-Aligned Community Team (PACT).

The PACT service is a collaboration with the Havering Place based Partnership aligning with its priorities of Age Well and Die Well. The service has been coproduced with service users, their loved ones, and staff. The PACT team aims to support older housebound individuals living with frailty or complex needs by:

providing a single point of contact for individuals and their carers proactively undertaking comprehensive geriatric assessment to identify holistic needs and develop high quality, personalised, anticipatory care to promote rehabilitation and prevent deterioration using networking skills to bring diverse stakeholders together to develop a single, integrated, community team around each individual, including specialist community services, social prescribers, voluntary sector organisations, GPs

Main duties of the job

The post holder will work alongside other care coordinators to support the work of the Advanced Clinical Practitioners (ACPs) and the PCN in delivering the PACT service. They will assist coordination of all key activity including access to services, advice, information, and ensuring health and care planning is timely, efficient, and patient-centred. The post holder will be based at a primary care site and may visit patients in their own homes.

The post holder will:

work closely and in partnership with the ACPs, PCN Manager and Clinical Director, and GP practices

support the PACT team through processing referrals, answering queries, making, and managing appointments. contribute to public health campaigns through advice or direct care. provide cross-cover to our other PCN care coordinators at times of annual leave and sickness. provide administrative support to the PACT team and GP practices. be able to deal with unpredictable work patterns and proactively deal with issues without reference to others.

About us

Havering Liberty Primary Care Network

We are a collaborative neighbourhoodhealthcare network of five General Practices serving the population with anextended multi-disciplinary team seeking to provide accessible,patient-centred, and high-quality primary care services that promote the healthand well-being of our community and our workforce.

The PCN supports numerous innovativeprojects, looking to improve the health and well-being of our community,including:

Working with North East LondonFoundation Trust, Care Providers and the Age Well Team to deliver targetedfalls prevention intervention to residents who have not fallen, but areidentified as 'at risk of falls'

Completing a pilot with Havering AccessTeam and the reablement provider ECL on avoidance admission for the populationof South Havering

PCN Care Coordinators in associationwith the Place lead for Learning Difficulties and BHR CEPN to complete trainingto support others to deliver the 'Gold Standard' of LD Health Checks within thePCN.

Social Prescriber projects supportingHigh Intensity Users, bereaved family/friends of recently deceased patients andidentifying carers to complete welfare checks.

The PCN works closelywith and is supported by its GP Federation, HH, who are theemploying body for the workforce of the PCN.The GP Federation supports the provision of innovative, high-quality andresponsible health care services for Haverings residents.

Job description

Job responsibilities

'Please note that this vacancy is not open to current Havering Health ARRS staff'

Aim of the role:

The post holder will be expected to support their team to achieve the PCNs Values in their day to day work.

Patient centred care and health equity

Sustainability and efficiency

Collaboration and team working

Quality and excellence

Inclusivity and respect

Accountability and integrity

The post holder will support the work of the PCN aligned community team (PACT) in Havering Liberty Primary Care Network.

In line with the Havering Place based Partnerships priorities of Age Well and Die Well, the PACT team aims to support older housebound individuals living with frailty or complex needs to live longer and healthier lives. PACT aims to achieve this by:

providing a single point of contact for individuals and their carers proactively undertaking comprehensive geriatric assessment to identify holistic needs and develop high quality, personalised, anticipatory care coordinating the provision of holistic, integrated care, through collaboration with other services/professionals, specialist community teams, social prescribers, voluntary sector organisations, GPs supporting the transition from hospital to home through consultation and collaboration with acute care partners

Key Responsibilities:

The post holder will work alongside other care coordinators to support the work of the Advanced Clinical Practitioners (ACPs) and the PCN in delivering the PACT service. They will assist coordination of all key activity including access to services, advice, information, and ensuring health and care planning is timely, efficient, and patient-centred. The post holder will be based at a primary care site and may visit patients in their own homes.

The post holder will:

work closely and in partnership with the ACPs, PCN Manager and Clinical Director, and GP practices

support the PACT team through processing referrals, answering queries, making, and managing appointments. contribute to public health campaigns through advice or direct care. provide cross-cover to our other PCN care coordinators at times of annual leave and sickness. provide administrative support to the PACT team and GP practices. be able to deal with unpredictable work patterns and proactively deal with issues without reference to others.

Administrative Skills:

Manage and maintain an efficient administrative system on behalf of others. Undertake word processing of all documents to a high standard, in an agreed style and using an appropriate referencing system. Utilise advanced level IT skills to create reports and presentations. Develop and maintain filing systems (electronic and paper) to ensure effective access to relevant information. Prioritise own workload on a day-to-day basis to ensure that deadlines are met. Coordinate administrative arrangements relating to reporting requirements, to include the collation and presentation of documentation, preparing evidence and ensuring information is up to date. Oversee the facilitation and administration of meetings, including the production of agendas, coordination of papers and minute taking, ensuring that key documents are available within defined timescales. Update databases for sharing of appropriate information with internal and external stakeholders. Establish and maintain electronic and manual filing systems. Type medical or other reports under supervision Input generic data into organisational systems or in-house records. Use the patient records system to enter client related information and care events. Prepare monthly team reports on service activity. Cover other services, where necessary, which may require working on other sites.

Education and Development:

It is the responsibility of the employee to comply with all organisational and statutory mandatory requirements (eg. health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance) and to complete the required training.

Engages in annual appraisal, developing objectives to inform a Personal Development Plan, which may include 360-degree appraisal and use of patient feedback.

Undertake education and training that is appropriate to the role of care coordinator, as identified in Professional Development Plan.

Contribute to the training of staff, using informal and formal teaching sessions.

Contribute to the development and updating of resource and teaching packs for use by patients and/or staff in the clinical and education settings.

Communication:

Communicate effectively with a range of people, either in person or on the telephone, promptly and in a professional and courteous manner whilst recognising barriers to communication.

Ensure that complex calls from anxious and distressed clients/loved ones are passed to appropriate person to deal with effectively and appropriately, or escalated to senior staff member if appropriate

Respond to enquiries, and take appropriate action on behalf of the service, either by telephone, personal contact or correspondence, within agreed time limits.

Communicate with other health care professionals and address interface issues within primary, community and secondary care to ensure consistent and accurate transfer of information relating to patient care.

Facilitate the smooth running of the service, dealing sensitively with any complaints, problems or issues arising, highlighting and referring problems as appropriate to the ACPs or PCN manager. Take clear messages and pass them promptly to the appropriate member of the team using own judgement on urgency. Demonstrate effective communication skills and promote a positive image of the team with service users, carers, professionals and external agencies from a variety of disciplines, both within and outside the PCN. Respond to frequent enquiries made by clients/staff, either in person or on the telephone, promptly and in a professional and courteous manner in line with local policy. Work competently within current procedures for own working practices and, where appropriate, contribute to the development and implementation of changes to improve own working practices/service, policies, procedures and guidelines. Employ excellent written and verbal communication skills.

Clinical Governance

Contribute to the review of incidents and complaints, where appropriate

Be responsible for ensuring that accurate legible records are kept in accordance with local policies and legal requirements.

Report all complaints and incidents in accordance with local procedures and ensure that the line manager is informed.

Cooperate with any investigation within the organisation

Use audit and other measurement approaches to provide data to commissioners regarding the performance of the service

Quality Improvement

Propose and implement changes to working practices to reflect the needs of the Service.

Participate in project work and/or QI initiatives for the PACT service

Support the ACPs to collect performance data from service users, support service users to complete patient reported outcome measures

Participate in audits and surveys as necessary. Provide support in the development of audit reports

To continually explore advanced digital options for data sharing and access to patient clinical information to ensure prompt and effective patient care across the interface.

To understand and implement all relevant and local policies and procedures

Raise quality issues and related risks with team manager or senior manager.

Evaluate the quality of own work, making improvements when necessary.

Working Conditions

This post requires the post holder to travel from practice to practice and to other venues during fulfilment of their duties.

Person Specification

Qualifications

Essential

Grade C GCSE English and Maths or equivalent qualifications. Excellent computer skills including email, word and excel

Desirable

Has enrolled in, undertaking or qualified from appropriate training as set out by the Personalised Care Institute

Special Skills/Aptitudes

Essential

Strong organisational skills including planning, prioritising, time management, report writing and record keeping Ability to recognise gaps in services and to identify and act on safety concerns Ability to recognise and work within limits of competence and seek advice when needed Evidence of good verbal and written communication skills Ability to build and maintain long- term-working relationships with colleagues A professional and compassionate attitude to patient care, providing support while maintaining professional boundaries Ability to work effectively under pressure, delivering against agreed objectives Ability to remain diplomatic when dealing with sensitive matters or having challenging discussions with patients or carers Willingness to take a pro-active and flexible approach to the role as it develops over time Willingness to work across and travel between a number of sites

Desirable

Experience of using the EMIS computer system Up-to-date knowledge of the services and organisations available to support patients and carers

Experience

Essential

At least 2 years' experience of working in health, social care or other support roles in direct contact with people, families or carers (in a paid or voluntary capacity) Experience of working within multi- professional team environments Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Ability to collect and record information and data, for record- keeping, monitoring and evaluation

Desirable

Experience or training in person-centred care planning

Experience

Essential

At least 2 years' experience of working in health, social care or other support roles in direct contact with people, families or carers (in a paid or voluntary capacity) Experience of working within multi- professional team environments Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Ability to collect and record information and data, for record- keeping, monitoring and evaluation

Desirable

Experience or training in person-centred care planning

Experience

Essential

At least 2 years' experience of working in health, social care or other support roles in direct contact with people, families or carers (in a paid or voluntary capacity) Experience of working within multi- professional team environments Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Ability to collect and record information and data, for record- keeping, monitoring and evaluation

Desirable

Experience or training in person-centred care planning