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Care Co-Ordinator

3 months ago

Maidstone, United Kingdom Bower Mount Medical Practice Full time

Job summary

We are seeking a dedicated Care Co-Ordinator to assist us with improving services for patients who are residents within our Practice boundary. The post holder will be responsible for coordinating activities to deliver the directed enhanced services related work on behalf of Bower Mount Medical Practice, ensuring all residents receive coordinated, and high quality patient-care services. The post holder will be part of a multi-disciplinary team supporting the Practice to achieve safe and high quality care.

Main duties of the job

The post holder will

Be responsible for co-ordinating work supporting Bower Mount Medical Centre in delivering the DES specification within its localities

Work closely and in partnership with the Social Prescribing Link Worker(s) or social prescribing service provider and Health and Wellbeing Coach(es),

Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN;

Support for care home / DES

Support the coordination and delivery of MDTs within the Practice and if required within the MC PCN.

Care Coordinator(s) can discuss patient related concerns and be supported to follow appropriate safeguarding procedures ( abuse, domestic violence and support with mental health) with a relevant GP.

About us

Here at Bower Mount Medical Practice we are a friendly team, responsible for the care of circa 11,000 patients, including residents of a number of local care and residential homes.

Our mission is to provide professional, accessible, quality healthcare services for our patients, providing the best possible outcomes for our patients in a safe and welcoming environment. We strive to be a modern general practice, offering a wide range of services. We aim to be a Centre of Excellence for teaching and training of medical students and GP Registrars, as well as investing in our staff team to develop their skills and knowledge.

We are situated in central Maidstone, and offer free parking for staff.

Job description

Job responsibilities

Care Co-Ordinator Job Description:

Responsible to : HR Lead

Base: Bower Mount Medical Practice

Hours per week: Circa 20

Holiday Entitlement: 25 days per year pro rata

Will liaise with: Clinical Lead, HR Lead, PCN Pharmacists, GPs within Network, Multi-Disciplinary Teams (MDT), Provider Organisations, Voluntary Sector,( not an exhaustive list).

The post holder will

} Be responsible for co-ordinating work supporting Bower Mount Medical Centre in delivering the DES specification within its localities

} Work closely and in partnership with the Social Prescribing Link Worker(s) or social prescribing service provider and Health and Wellbeing Coach(es),

} Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN;

} Support for care home / DES

} Support the coordination and delivery of MDTs within the Practice and if required within the MC PCN.

} Care Coordinator(s) can discuss patient related concerns and be supported to follow appropriate safeguarding procedures ( abuse, domestic violence and support with mental health) with a relevant GP.

Key Responsibilities:

To work with the GPs and other primary care professionals within the practice to identify and manage a caseload of patients.

To work closely and in partnership with service providers and other practices within the PCN

To support patients to utilise decision aids, help create single personalised care and support plans, in line with best practice.

Work with secondary care in helping facilitate discharge of patients to the right setting with the appropriate care available.

Work with all providers to establish training needs within the wider workforce

To support the Clinical Directors in the delivery of the enhanced service specifications.

To provide coordination and navigation with the aid of digital tools for people and their carers across health and care services.

To support the coordination and delivery of multi-disciplinary meetings between care home and providers.

Consult and collaborate with other health care providers.

Check-in regularly with service providers, evaluate and document their progress.

Be the First point of contact between the care home and primary care and liaise between.

Assist the care home and multi-disciplinary team with developing health interventions.

Attend ongoing training and courses to keep abreast of new developments in health care.

Treat patients with empathy and respect and conduct oneself in a professional manner.

Comply with organizational guidelines and health care laws and regulations.

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care;

Support patients to utilise decision aids in preparation for a shared decision-making conversation;

Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person;

Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care;

Support people to take up training and employment, and to access appropriate benefits where eligible;

Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure;

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level

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, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals;

IM&T

Ensure compliance with the GDPR and FOI along with other relevant legislation and professional information management standards such as GMC/BMA and LMC guidance

Embed the usage of digital and telemedicine as service delivery support modalities in the PCN locality

Working Relationships:

Work as a flexible member of the practice, providing support to other team members when necessary.

Encourage and support staff to collaborate through sharing information and intelligence across different activities.

Equality and Diversity:

The Care Coordinator will support the equality, diversity and rights of patients, carers and colleagues, to include:

Management:

Uses resources effectively to manage patient treatment in line with local guidance and makes recommendations for change where improvements can be made.

Follows professional and organisational policies

Education, learning and development:

It is the responsibility of the employee to comply with all organisational and statutory requirements including appraisal land performance management and quality improvement ( health and safety, infection control, equality and diversity, confidentiality, safeguarding adults and children, information governance).

Person Specification

Qualifications

Essential

GCSE Mathematics and English (or equivalent). Full UK driving license required as the role needs home visits

Desirable

Training in motivational coaching and interviewing. NVQ Level 3 or equivalent in health and social care.

Experience

Essential

Experience of supporting people, their families & carers in a related role. Good experience of IT systems and packages. Experience of data collection and providing monitoring information. Experience of working within a patient facing role. Experience of Electronic Patient Records. Knowledge of the purpose of departmental policies, procedures and care pathways.

Desirable

Experience of using EMIS, Docman and other clinical systems. Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement (including unpaid work). Experience of supporting people with their mental health. Experience of collaborative working and building relationships across varied organisations.