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Nurse Care Coordinator
4 months ago
Job summary
We are an 11,000 patient Practice on the Isle of Sheppey in Kent and are looking for a Care Coordinator to join our hard-working dedicated team.
You must have an excellent attendance record, be a good timekeeper, able to work under pressure and enjoy working as part of a team. The successful candidate will be flexible, motivated, reliable, conscientious and committed to making a valuable contribution to the team. The successful candidate will be based in the local cluster of GP Surgeries as part of Sheppey Primary Care Network (PCN).
Working hours are to be confirmed.
Main duties of the job
Care coordinators play an important role within a PCN toproactively identify and work with people, including the frail/elderly andthose with long-term conditions, to provide coordination and navigation of careand support across health and care services.
They work closely with GPs and Practice teams to manage acaseload of patients, acting as a central point of contact to ensureappropriate support is made available to them and their carers; supporting themto understand and manage their condition and ensuring that their changing needsare being met.
This is achieved by bringing together all the informationabout a persons identified care and support needs and exploring options tomeet these within a single, personalised care and support plan, based on whatmatters to the patient.
Care coordinators review patients needs and help them toaccess the services and support they require to understand and manage their ownhealth and wellbeing, referring to social prescribing link workers, health andwellbeing coached, and other professionals where appropriate.
Care coordinators could potentially provide time, capacityand expertise to support patients in preparing for, or following up, clinicalconversations they have with primary care professionals to enable them to beactively involved in managing their care and supported to make choices that areright for them. Their aim is to help patients improve their quality of life.
About us
We have one main site in Sheerness, with three other branch sites at Eastchurch, Warden Bay & Leysdown
Job description
Job responsibilities
KeyResponsibilities
Work with patients, their families and carers inorder to improve their understanding of the patients condition and supportthem to develop and review personalised care and support plans to manage theirneeds and achieve better healthcare outcomes
Help patients to manage their needs throughanswering queries, making and managing appointments, and ensuring the patientshave good quality written or verbal information to help them make choices abouttheir care
Support patients to understand their level ofknowledge, skills and confidence when engaging with their health and wellbeing
Assist patients to access self-managementeducation courses, peer support or interventions that support them in theirhealth and wellbeing
Support patients who take up training andemployment, and to access appropriate benefits where eligible
Provide coordination and navigation for patientsand their carers across health and care services, working closely with socialprescribing link workers, health and wellbeing coaches, and other primary careprofessionals; helping to ensure patients receive a joined up service and themost appropriate support
Work collaboratively with GPs and other primarycare professionals within the PCN to proactively identify and manage acaseload, which may include patients with long-term health conditions, andwhere appropriate, refer back to other health professionals within the PCN
Support the coordination and delivery ofmultidisciplinary teams with the PCN
Raise awareness of how to identify patients whomay benefit from shared decision making and support PCN staff and patients andto be more prepared to have shareddecision making conversations
Explore and assist patients to access a personalhealth budget where appropriate
Key Tasks
1.Enable access to personalised care and support
a.Take referrals for individuals or proactivelyidentify patients who could benefit from support through care coordination
b.Have a positive, empathetic and responsiveconversation with the patient and their family and carer(s) about their needs
c.Support patients to develop and implementpersonalised care and support plans
d.Review and update personalised care and supportplans at regular intervals
e.Ensure personalised care and support plans arecommunicated to the GP and any other professionals involved in the patientscare and uploaded to the relevant online care records, with activity recordedusing the relevant codes
f.Where a personal health budget is an option, towork with the patient and the local ICB to provide advice and support asappropriate
2.Coordinate and integrate care
a.Help patients transition seamlessly betweenservices and support them to navigate through the health and care system
b.Refer onwards to social prescribing link workersand health and wellbeing coaches where required
c.Regularly liaise with the range ofmultidisciplinary professionals and colleagues involved in the patients care,facilitating a coordinated approach and ensuring everyone is kept up to date sothat any issues or concerns can be appropriately addressed and supported
d.Actively participate in multidisciplinary teammeetings in the PCN as and when appropriate
e.Identify when action or additional support isneeded, alerting a named clinical contact in addition to relevant professionals,and highlighting any safety concerns
This post issubject to the Rehabilitation of Offenders Act (Exceptions Order) 1975, and assuch it will be necessary for a submission for disclosure to be made to theDisclosure & Barring Service (formerly CRB) to check for any previouscriminal convictions.
Communication
Thepost holder should recognise the importance of effective communication withinthe team and will strive to:
Communicate effectively with other team members
Communicate effectively with patients and carers
Recognise peoples needs for alternative methods ofcommunication and respond accordingly
Confidentiality
In the courseof seeking treatment, patients entrust us with, or allow us to gather,sensitive information in relation to their health and other matters. They do soin confidence and have the right to expect that staff will respect theirprivacy and act appropriately In theperformance of the duties outlined in this job description, the post-holder mayhave access to confidential information relating to patients and their carers,practice staff and other healthcare workers. They may also have access to informationrelating to the practice as a business organisation. All such information fromany source is to be regarded as strictly confidential Informationrelating to patients, carers, colleagues, other healthcare workers or thebusiness of the practice may only be divulged to authorised persons inaccordance with the practice policies and procedures relating toconfidentiality and the protection of personal and sensitive data
Qualities
The post-holder will participate in any training programmeimplemented by the practice as part of this employment, such training toinclude: Participation in an annual individualperformance review, including taking responsibility for maintaining a record ofown personal and/or professional development Taking responsibility for own development,learning and performance and demonstrating skills and activities to others whoare undertaking similar work
Health & Safety
The post-holder will assist inpromoting and maintaining their own and others health, safety and security asdefined in the practice Health & Safety policy, the Health & Safetymanual, and the Practice Infection Control policy and published procedures.This will include:
Using personalsecurity systems within the workplace according to practice guidelines
Identifying therisks involved in work activities and undertaking such activities in a way thatmanages those risks
Making effectiveuse of training to update knowledge and skills
Using appropriateinfection control procedures, maintaining work areas in a tidy and safe way andfree from hazards
Activelyreporting of health and safety hazards and infection hazards immediately whenrecognised
Keeping own workareas and general/patient areas generally clean, assisting in the maintenanceof general standards of cleanliness consistent with the scope of thepost-holders role
Undertakingperiodic infection control training (minimum annually)
Reportingpotential risks identified
Demonstrate dueregard for safeguarding and promoting the welfare of children
Equality& Diversity
The post-holder will support theequality, diversity and rights of patients, carers and colleagues, to include:
Acting in a waythat recognises the importance of peoples rights, interpreting them in a waythat is consistent with Practice procedures and policies and currentlegislation
Respecting theprivacy, dignity, needs and beliefs of patients, carers and colleagues
Behaving in amanner which is welcoming to and of the individual, is non-judgemental andrespects their circumstances, feelings, priorities and rights
Thisjob description is a reflection of the current position and may change inemphasis or detail in the light of subsequent development, in consultation withthe post holder.
Person Specification
Personal Attributes
Essential
Ability to actively listen, empathise and provide personalised support in a non-judgemental way, to inspire trust and confidence and motivate people to reach their potential Ability to provide a culturally sensitive service, supporting people from all background and communities, respecting lifestyle and diversity Commitment to reducing health inequalities and proactively working with to reach people from diverse communities High level of written and verbal communication skills and the ability to communicate effectively both verbally and in writing, with people, their families, carers and other stakeholders. Ability to identify risk and assess and manage when working with individuals Have a strong awareness and understanding of when it is appropriate to refer back to other health professionals/agencies Ability to maintain effective working relationships with all colleagues and work flexibly and enthusiastically within a team or working under own initiative To promote collaborative working Ability to demonstrate personal accountability, resilience and work well under pressure Ability to organise, plan and prioritise under own initiative and when under pressure and meeting deadlines Knowledge of, and ability to work to, policies and procedures including confidentiality, safeguarding, information governance and health and safety
Qualifications
Essential
Experience of working within healthcare Registered General Nurse (degree level) Commitment to professional development Experience of working with multi-professional team environment Experience of dealing with public/patients Experience of supporting people, their families or carers in a related role Experience of working in accordance with the UKCC Code of Practice Experience of data collection and using audits to measure the impact of services Demonstrable commitment to professional and personal development Ability to use Microsoft Office applications Experience or training in personalised are and support Experience in Chronic Disease Management Current emergency resuscitation training certificate Experience of EMIS Web clinical system Experience of Docman10 Experience of infection prevention and control measures
Knowledge & Skills
Essential
Strong organisational skills including planning, prioritising, time management and record keeping Strong IT skills to include EMIS, Docman, Word, Excel and experience of using databases Ability to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients, including GPs, Practice Nurses, healthcare professionals and other staff Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers Understanding the needs of older people/adults with disabilities/long-term conditions particularly in relation to promoting independence Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social Ability to recognise and work within limits of competence and seek advice when needed Willing to travel across PCN sites if/when required Familiar with local resources and services and how to access them Knowledge of the NHS works, including PCNs Knowledge of safeguarding policies and processes Ability to record accurate clinical notes Ability to work within own scope of practice and understand when to refer to GP Broad knowledge of clinical governance Understanding the importance of evidence-based practice