Care Coordinator

Job summary

The Care Coordinator will work as part of amultidisciplinary team (MDT) within a GP practice to identify people in need of proactivesupport. This could be, for example, people who are frail or have multiplelong-term physical and mental health conditions.

They work with people individually, buildingtrusting relationships and listening closely to what matters to them to developa personalised care and support plan. This includes reviewing their needs andhelping to connect them to the services and support they require within thepractice or elsewhere, for example community and secondary services.

Another key part of the role is to provide supportfor people who are preparing for clinical conversations with healthcareprofessionals or following up on those conversations, to ensure they can beactively involved in managing their care and supported to make choices that areright for them. Care coordinators work closely with GPs and practice teams tohelp manage caseloads. They act as a central point of contact so thatappropriate support can be made available to individuals and their carers whichhelps them to manage their condition and addresses their needs.

Main duties of the job

The care coordinatoris to play a key role inproactively identifying and working with people, including the frail/elderlywith long-term conditions, to provide coordination and navigation of care andsupport across health and care services.

ThePractice Care coordinator will provide senior support to the practice team intargeting hard to reach groups with a focus on inequalities including Core20Plus 5 groups andandpatients.

The Care Coordinator will reviewpeoples identified needs and help to connect them to the services and supportthey require, whether within the practice or elsewhere for example, communityand hospital-based services.

Working closely with social prescribing link workers, health andwellbeing coaches, and other primary care professionals' team to provide an all-encompassingapproach to personalised care and enable people navigate through the health andcare system.

Identifying target areas such as long-term conditions, frailty, DES, QOFand IIF targets. Support practices in achieving their recall targets andproviding an enhanced outreach service to those hard-to-reach groups.

Identifying patients requiring proactive support , hard to reachpatients, high risk patients as identified in MDTs/practice meetings.

Working with patients to improve their access to primary care servicesand comply with the requirements of the PCN Capacity and Access Improvementplan including the transformation elements of new triage processes.

About us

Sunderland GP Alliance is a not-for-profit collaboration of GP practices in Sunderland.

All GP Practices in Sunderland are members of the organisation, covering approximately 285,000 patients.

The Alliance also runs three practices in Washington, South Hylton and New Silksworth.

Formed in 2015, Sunderland GP Alliance is an organisation owned by the GP Practices of Sunderland, it exists to help GPs work collaboratively for the benefit of patients and staff.

All GP practices in Sunderland are members of the organisation. The Alliance works on a not-for-profit basis, ensuring any surplus is reinvested back into better services for patients.

Organisations such as ours help General Practice respond to the changing needs of the health system. Many of the services we provide cannot be delivered by individual GP surgeries. Our COVID vaccination programme, our community integrated team support and our enhanced access service are all good examples of this; In the enhanced access service only by working together with all the practices can we offer patients the convenience of appointments with members of the GP team on weekday evenings and during the day on weekends in locations across the city within their neighbourhoods. This is often referred to as federated working.

Job description

Job responsibilities

Main Duties andResponsibilities

Utilise population health intelligence to proactively identify and workwith a cohort of patients to deliver personalised care. Support patients to utilise decision aids in preparation for a shareddecision-making conversation. Holistically bring together all a persons identified care and supportneeds and explore options to meet these within a single personalised care andsupport plan (PCSP), in line with PCSP best practice, based on what matters tothe person. Help people to manage their needs through answering queries, making, andmanaging appointments, and ensuring that people have good quality written orverbal information to help them make choices about their care, using tools tounderstand people's level of knowledge, confidence in skills in managing theirown health. Provide coordination and navigation for people and their carers acrosshealth and care services, working closely with social prescribing link workers,health and wellbeing coaches, and other primary care professionals. Support the coordination and delivery of MDTs. Scheduling patienttreatments and co-ordinating the initial visit and follow-up visits Co-ordination of reminder procedures.Diary management in liaison with practice staff. Setting up of specialist appointments,including letters and records, and follow-up on care and outcomes

Preparation of treatment plan andexplanation of treatment plans to patients, and dealing with patient questions

Following up patient decisions ontreatments where these are not initially taken up. Participating in the administrativeresponsibilities of the practice team , DES, QOF IIF targets Ensuring accurate and legible notesof all consultations and treatments are recorded in patients and accuratecompletion of all necessary documentation associated with patient health care. Attending and participating inmeetings as required , MDTs, practice meeting (DES, QOF and IIF targetmeetings) Providing services for the PCN

Safeguarding

To comply with local safeguardingprocesses for children and vulnerable individuals.

Health and Safety

To comply with the Health andSafety at Work etc Act 1974 To take responsibility for his/herown health and safety and that of other persons who may be affected by his/her ownacts or omissions. Making effective use of trainingto update knowledge and skills. Using appropriate infectioncontrol procedures, maintaining work areas in a tidy and safe way and free fromhazards. Reporting potential risksidentified.

Equalityand diversity

The post-holder will support theequality, diversity and rights of patients, carers, and colleagues by:

Acting in a way that recognises theimportance of peoples rights, interpreting them in a way that is consistentwith practice procedures, policies, and current legislation. Respecting the privacy, dignity, needsand beliefs of patients, carers, and colleagues. Behaving in a manner which iswelcoming. Behaving in a manner that isnon-judgmental and respects circumstances, feelings, priorities, and rights

Risk Management and Clinical Governance

Towork within the Clinical Governance Framework of the GP Practice, incorporatingRisk Management and all other quality initiatives

General

To undertake any other dutiescommensurate with the role, within the bounds of his/her own competence

The post holder is expected to be flexible andaccommodating, following consultation, in terms of any changes in the future.

CONFIDENTIALITY

Inthe performance of the duties outlined in this job description, the post-holdermay have access to confidential information relating to patients and theircarers, Practice staff and other healthcare workers. All such information from any source is to beregarded as strictly confidential. Informationrelating to patients, carers, colleagues, other healthcare workers or thebusiness of the Alliance may only be divulged to authorized persons inaccordance with the Alliances policies and procedures relating toconfidentiality, and the protection of personal and sensitive data.

Quality

Thepost-holder will strive to maintain quality within the Alliance, and will:

Alert other team members to issuesof quality and risk. Assess own performance and takeaccountability for own actions, either directly or under supervision. Contribute to the effectiveness ofthe team by reflecting on own and team activities and making suggestions onways to improve and enhanced the teams performance. Work effectively with individualsin other agencies to meet patients needs. Effectively manage own time, workload,and resources. Communication Thepost-holder should recognize the importance of effective communication withinthe team and will strive to: Communicate effectively with otherteam members. Communicate effectively withpatients and carers. Recognise peoples needs foralternative methods of communication and respond accordingly.

Other

Undertake anytasks consistent with the level of the post and the scope of the role, ensuringthat work is delivered in a timely and effective manner. Duties mayvary from time to time, without changing the general character of the post orthe level of responsibility. Person Specification

Qualifications

Essential

Demonstrable commitment to personal and professional development Proficient in the use of Microsoft Office applications. Able to provide a culturally sensitive service supporting people from all backgrounds and communities respecting lifestyle and diversity. Must be a car driver.

Desirable

Experience of working in general practice Knowledge of how the NHS works, primary care and PCN's.

Experience

Essential

Excellent communication skills and an ability to engage successfully with a wide range of people at all levels. Experience of collecting and recording confidential information and data Ability to identify risk to self and others, Identifying and reporting safeguarding incidents. Ability to actively listen and empathise with people and provide personalised support in a non judgement way. Basic knowledge of long-term conditions and the complexities involved; medical, physical, emotional, and social. The ability to work calmly under pressure. The ability to adapt your leadership and management style to different situations. Experience of championing diversity and inclusion and promoting actions to make improvements to the experience of diverse groups

Desirable

Experience of working in a multi setting complex programme environment Experience of working in a community setting Extensive knowledge of local services within a Sunderland through either living or working within one of the wider Sunderland settings. Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work Ability to provide motivational coaching to support people's behaviour change. NVQ Level 3 in adult care, advanced level or equivalent qualifications or working towards.

Motivation and Skills

Essential

Outstanding organisational skills, able to prioritise and work to deadlines. Work effectively and collaboratively as part of a team but also autonomously. Promote and maintain good working relationships with a variety of external partners. Keep accurate records of discussions and clearly replicate discussions in writing. Work on own initiative but within constraints of the role Understanding of and commitment to equality, diversity, and inclusion Ability to competently use technology and IT systems including word processing, email, and the internet to create simple personalised plans with individuals Ability to work across multiple sites in the Sunderland area. Confident and comfortable with difficult situations Patient, friendly and approachable Able to work under pressure and emotionally resilient. Ability to work flexible hours which may include occasional evenings or weekends with notice.

Desirable

Understanding the impact of economic and environmental factors on people's health and wellbeing

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