Care Coordinator

Job summary

As we develop our PrimaryCare Network (PCN) we are looking for a Care Coordinator to join our existingteam and help the PCN support our community and improve the health andwellbeing of our patients.

Care Coordinatorsplay an important role to identify and work with people, including thefrail/elderly and those with long-term conditions, to provide proactive coordinationand navigation of care and support across health and care services.

They work closelywith GPs and practice teams to manage a caseload of patients, acting as acentral point of contact to ensure appropriate support is made available tothem and their carers; supporting them to understand and manage their conditionand ensuring their changing needs are addressed.

The successfulcandidate will be based at Chiddingfold Surgery, part of West of Waverley PCN.They will be caring, dedicated, reliable and person-focussed and enjoy workingwith a wide range of people. They will have good written and verbalcommunication skills and strong organisational and time management skills. Theywill be highly motivated and proactive with a flexible attitude, keen to workand learn as part of a team and committed to providing patients, their familiesand carers with high quality support.

This role willbecome an integral part of our multidisciplinary team, working alongside SocialPrescribing Link Workers and others to provide personalised care and promote and embed the personalised care approach.

Main duties of the job

Care Coordinators will supportthe PCN and the practice to move from a reactive model of care to a moreproactive approach, helping to identify need and coordinate personalised carefor our population.

Care Coordinators reviewpatients needs and help them access the services and support they require tounderstand and manage their own health and wellbeing, working closely with and referringto Social Prescribing Link Workers, Health and Wellbeing Coaches, SocialServices and other professionals where appropriate.

Care Coordinators can also provide time,capacity and expertise to support people in preparing for or following-upclinical conversations they have with other primary care professionals toenable them to be actively involved in managing their care and supported tomake choices that are right for them. Their aim is to help people improve theirquality of life.

About us

West of Waverley Primary CareNetwork covers four like-minded practices in the beautiful countryside of SouthWest Surrey covering a population of just under 50,000 patients including anon-affiliated single-handed practice. Our population has a highersocio-economic and age demographic than average.

Our practices are innovativeand well organised and perform highly for patient quality in surveys and inQuality Clinical Markers. Our Primary Care Network meetings are attended bypatient representatives from each practice.

Our Primary Care Network workswith three other PCNs as part of the Guilford & Waverley Health and CareAlliance, supported by the Procare GP Federation. Procare is the employer for all our PCN roleswho are then seconded to work directly with the PCN for the duration of theircontract. The successful candidate willjoin our existing PCN team which includes the Clinical Director, GeneralManager, Pharmacists, Pharmacy Technicians, Care Coordinators and Physician Associate.

Job description

Job responsibilities

Jobresponsibilities

Support our PopulationHealth Management approach

Utilise population healthintelligence to proactively identify and work with a cohort of patients todeliver personalised care.

Support the coordination anddelivery of Multidisciplinary Teams (MDTs) within the PCN under theAnticipatory Care, Palliative Care & respect framework and also assist theGPs co-ordinating with the Traveller Community.

Support the development ofother services under the Network Contract Directed Enhanced Service, includingthe management of Long-Term Conditions through the facilitation of remotemonitoring.

Support patients

Support patients to utilisedecision aids in preparation for a shared decision-making conversation.Holistically bring together all of a persons identified care and support needsand explore options to meet these within a single personalised care and supportplan, in line with best practice, based on what matters to the person.

Help people to manage theirneeds through answering queries, making and managing appointments, and ensuringthat people have good quality written or verbal information to help them makechoices about their care. Using tools to understand peoples level of knowledgeand confidence skills in managing their own health.

Support people to take uptraining and employment, and to access appropriate benefits where eligible forexample, through referral to Social Prescribing Link Workers. Assist people to access self-managementeducation courses, peer support or interventions that support them to take morecontrol of their health and wellbeing.

Explore and assist people toaccess personal health budgets where appropriate.

Provide coordination andnavigation for people and their carers across health and care services, workingclosely with Social Prescribing Link Workers, Health and Wellbeing Coaches, andother primary care professionals.

Support PCN development

Develop an in-depth knowledgeof the local health and care infrastructure and know how and when to enablepeople to access support and services that are right for them.

Work with the GPs and otherprimary care professionals within the PCN to identify and manage a caseload ofpatients, and where required and as appropriate, refer people back to otherhealth professionals within the PCN.Support the transition of patients between primary, secondary andcommunity care services, supporting health and care professionals and theirpatients/clients navigate the system.

Work with the wider PCN, MDTs,and the social prescribing service to look at how carers can support people -this could include the initial identification of carers onto the carerregister.

Raise awareness within the PCNof shared decision-making and decision support tools.

Raise awareness of how toidentify patients who may benefit from shared decision making and support PCNstaff and patients to be more prepared to have shared decision-makingconversations.

Professionaldevelopment

Work with a named clinicalpoint of contact for advice and support.

Undertake continual personaland professional development, taking an active part in reviewing and developingthe role and responsibilities, and provide evidence of learning activity asrequired. The post holder would need toundertake appropriate training as set out by the Personalised CareInstitute as part of their personaldevelopment plan which the PCN would support in terms of funding and time.

Adhere to organisationalpolicies and procedures, including confidentiality, safeguarding, lone working,information governance, equality, diversity and inclusion training and healthand safety.

Please see attached job description for further information.

Please note, the employer will be Chiddingfold Surgery.

Person Specification

Experience

Essential

Experience of working in health, social care and 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 supporting people, their families and carers in a related role Experience or training in personalised care and support planning Experience of data collection and using tools to measure the impact of services

Desirable

Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Knowledge and Understanding

Essential

Knowledge of how the NHS works, including primary care and PCNs Knowledge of the personalised care approach Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers Understanding of, and commitment to, equality, diversity and inclusion An understanding of health inequalities and a commitment to reducing them and proactively working to reach people from diverse communities Ability to recognise and work within limits of competence and seek advice when needed, to have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, and when what the person needs is beyond the scope of the care coordinator role when there is a mental health need requiring a qualified practitioner Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social

Desirable

Knowledge of Safeguarding Children and Vulnerable Adults policies and processes

Other

Essential

Meets DBS reference standards Willingness to work flexible hours when required to meet work demands Able to work across several sites and travel to meet with stakeholders

Desirable

Holds a full, current UK driving licence

Skills and Competencies

Essential

Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders Ability to identify risk and assess / manage risk when working with individuals Ability to work from an asset-based approach, building on existing community and personal assets Ability to maintain effective working relationships and to promote collaborative practice with all colleagues High level of written and verbal communication skills Computer literate with a sound knowledge of Microsoft Office

Attributes

Essential

Demonstrate personal accountability, emotional resilience and work well under pressure Organised, plan and prioritise on own initiative, including when under pressure and meeting deadlines Personable and approachable, caring and sympathetic Self-confident and able to work with minimum direction Adaptable and innovative Enthusiasm, energy and drive Trustworthy, discrete, honest and reliable Determined and willing to persevere

Qualifications

Essential

Evidence of a sound general education (GCSEs or equivalent) to include English and Maths grade C or above

Desirable

NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards.

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