JOB OVERVIEW

Modality Partnership Birmingham Division has a full-time vacancy (Monday-Friday 10:00am-18:00pm) for a Care Coordinator. The postholder will be a high performing employee who will work as part of a multi-disciplinary team at Enki Medical Centre. We are seeking dedicated postholders to join our team and who can display our CARE values: Commitment, Accountability, Respect and Excellence.
This job is suitable for individuals who have a passion for working in health care, making a real difference providing seamless patient care, and who are committed to make real changes to the health care services provided within Primary Care to improve patient care. Salary for this role will be £23,874.97 per annum WTE.

JOB DESCRIPTION

Please refer to the supporting documents section to retrieve the JD detailing the core responsibilities of this role.
· As a Care Coordinator you will work as a key part of the multi-disciplinary team. You will be the key link to the people whose care you are supporting, operating as a go to person to ensure that their care is seamless, they are active decision makers in their own care, and that everyone involved is working together. Care coordinators provide extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals.
· You will work closely with the MDT including GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. This could mean supporting them to take up training or employment, access personalised health budgets, or take up other offers of support within the MDT.
· You will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions. An ethos of promotion of independence, shared decision making, personalisation and partnership-working is integral to this post. As the role evolves the care co-ordinator will undertake direct work with patients and families to develop personalised care plans.

· A key part of the role of a care coordinator role is in the care homes MDT. Care coordinators will improve the continuity of care by acting as a point of contact for residents, families and professionals who visit care homes, including MDT members and in-reach specialists. You will support the MDT with the weekly virtual home round through identification of people in need of review, or collation of information on people requiring an MDT review in addition to providing coordination, secretarial and administrative support to the MDTs within a single or multiple PCNs.

• Triaging referrals and allocating to appropriate clinician/service
• Post discharge follow up phone calls.
• Administrative duties including onward referrals and liaising with ICS services.
• Face to face Reviews and Following up on referrals.
• Coordinating care home monthly MDT (agenda, invites, minutes, follow ups)
• Co ordinating weekly MDT.
• Managing the watch list caseload of patient within the community/palliative patients
• Developing a directory of contact numbers for services
• Care navigation
• Audit
• Take overall responsibility for arranging the weekly PCN led MDT meetings (including the weekly virtual Care Home(s) ward round) and the smooth running of integrated care within the team setting. A key role of the Care Coordinator will be to schedule the weekly MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
• Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
• 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.
• Work with the PCN multi-disciplinary team to utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
• Support PCN staff and patients to be prepared to have shared decision making conversations, including utilising decision aids and tools.
• Holistically bring together all of a person’s 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.
• Raise awareness within the PCN of shared decision making and decision support tools, including how to identify patients who may benefit from this.
• As part of the PCN multi-disciplinary team, build relationships with staff in GP practices within the PCN, attending relevant MDT meetings, providing information and feedback on care coordination priorities.
• Liaise directly with Care Homes and other key providers, to identify patients for discussion at MDT, and compile and circulate relevant information to attendees.
• Be proactive in developing strong links with all local agencies to enable referrals, understanding their service offer and eligibility to enable appropriate referrals.
• Seek regular feedback about the quality of service and impact of care coordination on referral agencies.
• Be proactive in encouraging equality and inclusion, through self-referrals and connecting with all diverse local communities, particularly those communities that statutory agencies may find hard to reach.

· Work with the person, their families and carers and consider how they can all be supported by services available to them.
· Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards.
· Bring together a person’s identified care needs, and explore their options to meet these within a simple coproduced personalise care and support plan, including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
· Where people may be eligible for a personal health budget, help them to explore this option as a way of providing funded, personalised support to be independent, including helping people to gain skills for meaningful employment, where appropriate.
· Seek advice and support from the GP supervisor and/or identified individual(s) to discuss patient-related concerns (e.g. abuse, domestic violence and support with mental health), referring the patient back to the GP or other suitable health professional if required.

. Work sensitively with people, their families and carers to capture key information, enabling comprehensive and accurate records of support.

• Encourage people, their families and carers to provide feedback and engage fully in the care coordination process.
• Work closely within the MDT and with GP practices within the PCN to ensure that the comprehensive records of MDT case discussions are inputted into clinical systems, adhering to data protection legislation and data sharing agreements.
• Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
• Contribute to the development of policies and plans relating to equality, diversity and health inequalities.
• Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.

KNOWLEDGE:

Level 2 qualification in Maths and English.
Understanding of health and social care processes.
Knowledge and familiarity with medical terminology.
Understanding of social determinants of health and how these can be addressed with patients.
High levels of health literacy.
Excellent knowledge of Microsoft Office.
Educated to level 3 in a relevant topic, or working towards.
Knowledge of a range of technology and digital tools that can be used support health and wellbeing.
Understanding of current issues facing the NHS.
Sound understanding of disease prevention primary, secondary and tertiary and how patients can build prevention into their lifestyle.
Awareness of local services and resources for individuals, carers and families.

SKILLS:

Skilled in use of person-centred measurement & outcomes delivery.
Able to collate and disseminate voluminous and sometimes complex information.
Able to assess and work within an individual’s level of health literacy and support them to increase their understanding.
Proven record of excellent written and verbal communication skills.
Excellent motivational and influencing skills.
Excellent interpersonal skills.
Able to deal with service users sensitively.
Able to work as part of a team.
Able to prioritise and manage own workload.
Strong analytical and judgement skills.
Ability to analyse and interpret information and present results in a clear and concise manner Excellent organisational and administration skills.
Able to use asset-based approaches when working with individuals and families.
Able to use patient activation tools to measure knowledge, skills, and confidence in managing their own health and wellbeing.
Able to use NHS Choices website effectively.

MAIN DUTIES OF THE JOB

The role is both the delivery of evidence-based practice for patients presenting with a chronic condition, and the provision of preventative health care to the practice population. for the care delivered to their patients, demonstrating critical thinking and skills in clinical decision-making in the management of patients.
The role is not a regular 9am-5pm job; the job requires innovation, flexibility and commitment and the postholder will be required to work resourcefully as part of the team to ensure tasks are completed.

NB: THIS JOB DESCRIPTION OUTLINES THE KEY DUTIES THAT ARE EXPECTED OF YOU WITHIN THE ROLE ALTHOUGH IS NOT AN EXHAUSTIVE LIST. IT MAY BE AMENDED IN LINE WITH EXPERIENCE, BUSINESS REQUIREMENTS AND AS A RESULT OF ANY FUTURE ORGANISATIONAL CHANGE.

Your job is to work directly with key stakeholders to help us to harmonise ways of working and improve working practices to improve patient and staff satisfaction. Most management roles focus on personnel management / project management. This is a role that will equip you with a portfolio of skills to make sustainable changes within Primary Care. All employees are welcomed to enrol in our employee benefits scheme and NHS pension scheme. We are committed to developing our people through education and career pathways and who align to our organisational values of CARE.
You will love this job if you are able to work sensitively with patients their families and carers, are able to work as part of a healthcare team to seek feedback, continually improve the service and contribute to business planning.
If you feel this is the ideal opportunity for you and you want to rise to the challenge of this opportunity, we welcome an application for you to join our growing team of likeminded people.
Please Note: The Modality Partnership reserves the right to close this vacancy at any time during the advertising period.

· A key part of the role of a care coordinator role is in the care homes MDT. Care coordinators will improve the continuity of care by acting as a point of contact for residents, families and professionals who visit care homes, including MDT members and in-reach specialists. You will support the MDT with the weekly virtual home round through identification of people in need of review, or collation of information on people requiring an MDT review in addition to providing coordination, secretarial and administrative support to the MDTs within a single or multiple PCNs.

• Triaging referrals and allocating to appropriate clinician/service
• Post discharge follow up phone calls.
• Administrative duties including onward referrals and liaising with ICS services.
• Face to face Reviews and Following up on referrals.
• Coordinating care home monthly MDT (agenda, invites, minutes, follow ups)
• Co ordinating weekly MDT.
• Managing the watch list caseload of patient within the community/palliative patients
• Developing a directory of contact numbers for services
• Care navigation
• Audit
• Take overall responsibility for arranging the weekly PCN led MDT meetings (including the weekly virtual Care Home(s) ward round) and the smooth running of integrated care within the team setting. A key role of the Care Coordinator will be to schedule the weekly MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
• Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
• 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.
• Work with the PCN multi-disciplinary team to utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
• Support PCN staff and patients to be prepared to have shared decision making conversations, including utilising decision aids and tools.
• Holistically bring together all of a person’s 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.
• Raise awareness within the PCN of shared decision making and decision support tools, including how to identify patients who may benefit from this.
• As part of the PCN multi-disciplinary team, build relationships with staff in GP practices within the PCN, attending relevant MDT meetings, providing information and feedback on care coordination priorities.
• Liaise directly with Care Homes and other key providers, to identify patients for discussion at MDT, and compile and circulate relevant information to attendees.
• Be proactive in developing strong links with all local agencies to enable referrals, understanding their service offer and eligibility to enable appropriate referrals.
• Seek regular feedback about the quality of service and impact of care coordination on referral agencies.
• Be proactive in encouraging equality and inclusion, through self-referrals and connecting with all diverse local communities, particularly those communities that statutory agencies may find hard to reach