Job Description
Care Coordinator - PCN
We are looking to recruit to a care coordinator, to work within our Goldstone Primary Care Network team. Goldstone Primary Care Network is a network of 3 practices – Charter Medical Centre, Trinity Medical Centre and WellBN Wellbeing - with a combined list size of over 78,000 patients.
The post will be split over 3 sites - Charter Medical practice, Trinity Medical Practice and WellBN practice, all in Hove.
The successful candidate will play a key role in proactively identifying and working with people to provide coordination and navigation of care and support across health and care services.
They will work closely with practice teams including clinical teams, social prescribing workers and health and wellbeing coaches making sure appropriate support is made available to people.
The postholder will work with a diverse range of people from different cultural and social backgrounds. The ability to work confidently and effectively in a varied, and sometimes challenging environment is essential.
The successful candidate will have excellent interpersonal and communication skills, and be organised, patient and empathetic. They will have experience of working in health, social care or other support roles including direct contact with people, families or carers.
Salary start £12.50 per hour
Job Description – Care Coordinator
Purpose of the role
Care coordinators play an important role within a PCN to proactively identify and work with people, to provide coordination and navigation of care and support across health and care services.
They will work closely with practice teams including clinical teams, social prescribing workers and health and wellbeing coaches making sure appropriate support is made available to people.
The postholder will work with a diverse range of people from different cultural and social backgrounds. The ability to work confidently and effectively in a varied, and sometimes challenging environment is essential.
The successful candidate will have excellent interpersonal and communication skills, and be organised, patient and empathetic. They will have experience of working in health, social care or other support roles including direct contact with people, families or carers.
Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.
The successful candidate will be based in a local cluster of General Practices as part of Goldstone Primary Care Network (PCN). They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible
attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.
This role is intended to become an integral part of the PCN’s multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.
There may be a need to work remotely depending on the requirements of the role. Please note that the role of a care coordinator is not a clinical role.
Key responsibilities
· 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.
· 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; helping to ensure patients receive a joined-up service and the most appropriate support.
· Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
· Support the coordination and delivery of multidisciplinary teams with the PCN.
· Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.
· Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours;
· Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies;
· Identify unpaid carers and help them access services to support them;
· Conduct follow-ups on communications from out of hospital and in-patient services;
· Maintain records of referrals and interventions to enable monitoring and evaluation of the service;
· Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the person’s circumstances;
· Contribute to risk and impact assessments, monitoring and evaluations of the service;
· Work with commissioners, integrated locality teams and other agencies to support and further develop the role.
· 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 carer register
Work towards increasing patients’ understanding of how to manage and develop health and wellbeing through offering advice and guidance
Coordinate and integrate care
a. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations
b. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system;
c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required;
d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the person’s care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;
e. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate;
f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
g. Record what interventions are used to support people, and how people are developing on their health and care journey,
h. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation
Professional development
i. Work with a named point of contact for advice and support.
j. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required;
k. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Miscellaneous
l. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each other’s views and meeting regularly as a team;
m. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner;
n. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning;
o. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities;
p. Work in accordance with the practices’ and PCN’s policies and procedures;
q. Contribute to the wider aims and objectives of the PCN to improve and support primary care.
Job Type: Full-time
Salary: £12.50 per hour
Benefits:
- Company pension
- Cycle to work scheme
- Wellness programme
Schedule:
- Day shift
- Monday to Friday
Work Location: One location
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