TLCP Care Coordinator

Job summary

Job Title Care Coordinator

Salary Upto £ per hour

Line Manager Care Coordinator Supervisor/Assistant Supervisor

Accountable to Clinical Support Manager/Care First Chair

Hours per week hours per week(Minimum 30 hours per week)

Location TLCP Sites

Contract Type Permanent

The post holder will have a key role in supporting our TLCP 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

The care coordinator (CC) may be required to deal with patients and, if appropriate, their carers, before or after the patients consultation with a clinician or other healthcare professional.

The CCs role requires them to be able to work closely with the patient and their clinician or other healthcare professional and understand the roles of, a variety of different people working in the practice and across the PCN.

The CC will be involved in co-coordinating patients healthcare and directing them to the appropriate service to ensure that they get the most suitable care from whatever health or social care provider is appropriate

You may be given a caseload of identified patients and be required to ensure that their changing or present needs are addressed by taking into account local priorities, health inequalities and/or population health management risk stratification.

Main duties of the job

Primary Responsibilities

The following are the core responsibilities of the care coordinator. There may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:

Support Quality and Outcome Frameworks, PCN and other LES and DES specifications Maintain and develop engagement with appropriate TLCP colleagues and encourage best practice Act as the first port of call for patients, in their caseload in relation to their care. Support and Manage clinical call and recall Bring together all of a persons identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP) Working across TLCP to manage the needs of patients in Care Homes, supported accommodation or trying to remain living at home Performance targets - Ensure all patients receive enhanced care in a timely fashion and any other aspect of managing the patient facing service. Support with the performance/KPIs dashboards. Undertake audits for dashboards/KPIs To work as part of a multi-disciplinary team in a patient facing role to assess and respond to patients and colleagues using their expert knowledge To be responsible for arranging assessment of new patients with subsequent production and completion of individual care plans by appropriate clinicians Support the coordination and delivery of MDTs for their patient cohort

About us

TLCP Partnership aims to provide high quality health care in a responsive, supportive, courteous and cost-effective manner. We will:

Provide a service which puts patient welfare at the heart of all we do Work within the framework of NHS Primary Care Services to provide professional medical, nursing and other services which meet the identified needs of patients Promote best practice through utilising specialist expertise within the practice team and externally and encouraging the continuous professional development of all members of the practice team Nurture a culture which is innovative, forward looking and adaptable Take into account the evidence provided by scientific and medical research in our treatment

Values

Caring for wellbeing in body, mind, spirit and relationships Conveying compassion in word and action Assessing and responding to needs Providing an appropriate range of services Maintaining a health promoting environment Respecting all Showing courtesy Seeking to understand Treating all fairly Valuing each person as a unique individual Being especially supportive to the vulnerable Working as a team Relating well within the team Valuing the contribution of each team member Building a mutually supportive environment Co-operating with other teams Encouraging responsible involvement by our patients

Integrity

Speaking and acting truthfully Being accountable for our actions

Learning and improving

Adapting to change Building on achievements Developing our services Job description

Job responsibilities

Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids

Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance Support national screening and immunisation programmes and health checks/screening Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact Direct liaison with multiple agencies to coordinate care for patients Refer to social prescribing link workers or health coaches were a patient is identified as potentially benefitting from this service To support patient/carer contact roles, and collate patient and carer feedback on their experiences Raise awareness of shared decision-making and decision support tools, and assist people to be more prepared to have a shared decision-making conversation Ensure that people have good quality information to help them make choices about their care Support people to understand their level of knowledge, skills and confidence their Activation level when engaging with their health and wellbeing, including using the Patient Activation Measure Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing Explore and assist people to access personal health budgets where appropriate. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles. Support the coordination and delivery of MDTs for their patient cohort

Generic Responsibilities

All staff at The Lewisham Care Partnership(TLCP) have a duty to conform to the following:

Equality, Diversity & Inclusion

A good attitude and positive action towards ED&I creates and environment where all individuals are able to achieve their full potential. Creating such an environment is important for three reasons: it improves operational effectiveness, it is morally the right thing to do, and it is required by law.

Patients and their families have the right to be treated fairly and be routinely involved in decisions about their treatment and care. They can expect to be treated with dignity and respect and will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Patients have a responsibility to treat other patients and our staff with dignity and respect.

Staffs have the right to be treated fairly in recruitment and career progression. Staff can expect to work in an environment where diversity is valued and equality of opportunity is promoted. Staff will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Staffs have a responsibility to ensure that you treat our patients and their colleagues with dignity and respect.

Safety, Health, Environment and Fire (SHEF)

TLCP is committed to supporting and promoting opportunities to for staff to maintain their health, well-being and safety. You have a duty to take reasonable care of health and safety at work for you, your team and others, and to cooperate with employers to ensure compliance with health and safety requirements. All personnel are to comply with the Health and Safety at Work Act 1974, Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.

Confidentiality

TLCP is committed to maintaining an outstanding confidential service. In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients, their carers, practice or staff information. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, or the members practices may only be divulged to authorised persons in accordance with PGPA policies and procedures relating to confidentiality and the protection of personal and sensitive data, or under the guidance of your manager.

This role profile is not exhaustive, and you may be directed to complete other tasks according to the skills and requirements for individual roles. These duties will always be reasonable and deemed within the expectations of your position.

Quality & Continuous Improvement (CI)

To preserve and improve the quality of our output, all personnel are required to think not only of what they do, but how they achieve it. By continually re-examining our processes, we will be able to develop and improve the overall effectiveness of the way we work. The responsibility for this rests with everyone working within the practice to look for opportunities to improve quality and share good practice.

We continually strive to improve work processes which deliver health care with improved results across all areas of our service provision. We promote a culture of continuous improvement, where everyone counts and staffs are permitted to make suggestions and contributions to improve our service delivery and enhance patient care.

Induction Training

As part of the TLCP, all personnel are to complete a induction programme; this is managed by the Manager.

Learning and Development

The effective use of training and development is fundamental in ensuring that all staffs are equipped with the appropriate skills, knowledge, attitude and competences to perform their role. All staff will be required to partake and complete mandatory training as directed by the training coordinator, as well as participating in the TLCP training programme. Staff will also be permitted (subject to approval) to undertake external training courses which will enhance their knowledge and skills, progress their career and ultimately, enable them to improve processes and service delivery.

Collaborative Working

All staffs are to recognise the significance of collaborative working. Teamwork is essential in multidisciplinary environments. Effective communication is essential and all staff must ensure they communicate in a manner which enables the sharing of information in an appropriate manner.

Service Delivery

Staff at The Lewisham Care Partnership must adhere to the information contained with the policies and regional directives, ensuring protocols are adhered to at all times. Staff will be given detailed information during the induction process regarding policy and procedure.

Security

The security of the site of work is the responsibility of all personnel. Staff must ensure they remain vigilant at all times and report any suspicious activity immediately to their line manager. Under no circumstances are staffs to share the codes for the door locks to anyone and are to ensure that restricted areas remain effectively secured.

Professional Conduct

At The Lewisham Care Partnership, staffs are required to dress appropriately for their role.

Leave

All personnel are entitled to take leave. Line managers are to ensure all of their staff are afforded the opportunity to take a minimum of four weeks plus bank holiday days leave each year(pro rota for part time), and should be encouraged to take all of their leave entitlement.

Person Specification

Skills

Essential

Excellent communication skills (written and oral) A clear understanding of child protection policy and procedures and commitment to the safeguarding of children and vulnerable adults Clear, polite telephone manner EMIS/SystmOne/Vision user skills Effective time management (planning and organising) Ability to listen, empathise with people and provide person centred support in a non-judgemental way Courteous, respectful and helpful at all times Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity Commitment to reducing health inequalities and proactively working to reach people from all communities Able to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to use own initiative, discretion and sensitivity Ability to work as a team member and autonomously Good interpersonal skills Problem solving and analytical skills Ability to follow policy and procedure

Desirable

Experience in use of the Patient Activation Measure (PAM) Good IT skills

Experience

Essential

Experience of working in a primary care setting

Qualifications

Desirable

The Care Coordinator is enrolled in, undertaking or qualified in appropriate training as set out by the Personalised Care Institute Passed training requirements as outlined by the Personalised Care Institute and fully understands the Personalised Care Framework

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