Care Coordinator - Haywards Heath Central PCN

at  Alliance for Better Care

Reports to: Operations Manager
Responsible to: PCN Clinical Director
Proposed salary: Band 4.1 – 4.7 on the ABC pay scale which is equivalent to £23,285.69 - £25,709.29 per annum dependent on experience, pro rata
Hours of work: Full time (37.5 hours) and part-time applications will be considered
Base: The successful candidate will be based predominantly at Dolphins Practice but there may be a need to cross cover to support both Core Network Practices as needed

JOB SUMMARY

This role is to support the smooth co-ordination of patient care for one practice within the Primary Care Network for the benefit of our patients.
The Care Coordinator will be responsible for consulting with patients and determining their needs, developing care plans, coordinating patient-care services, educating them about their condition, empowering them to be independent whenever possible and working with the care team to evaluate interventions.

KNOWLEDGE & EXPERIENCE

Essential

• Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety

Desirable

• Experience of working directly in either the NHS or Adult Social Care

QUALIFICATIONS

Essential

• Demonstrable commitment to professional and personal development with a can do attitude.

Desirable

• NVQ Level 3, Advanced level or equivalent qualifications or working towards
• Training in motivational coaching and interviewing or equivalent experience

SKILLS & ABILITIES

Essential

• Able to listen, empathise with people and provide person- centred support in a non-judgemental way
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
• Committed to reducing health inequalities and proactively working to reach people from all
• communities
• Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
• Able to identify risk and assess/manage risk when working with individuals
• Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner
• Able to provide leadership and to finish work tasks
• Able to maintain effective working relationships and to promote collaborative practice with all colleagues
• Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues
• Demonstrates personal accountability, emotional resilience and works well under pressure Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• High level of written and oral communication skills

Desirable

• Excellent IT skills including Excel as well as knowledge of GP clinical systems, experience of data entry and coding

Key Responsibilities and Duties

• To work at one base within a Primary Care Network.
• To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence.
• To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patient’s home if needed.
• Liaise with Care Homes as necessary.

MDT Coordination

• Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting.
• Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions.

Managing a caseload

• Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence.
• Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions.
• Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacy team, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews.
• With the help of relevant clinical colleagues, develop a care plan to address patients’ personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare.
• Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans.
• Check in on the patient regularly and evaluate and document their progress.

Linking with other services

• Signpost team members, service users and carers to relevant services including the PCN Social Prescribing Link Worker Service.
• Liaise with the Social Prescriber and Mental Health Support Coordinator regarding patients that are identified as needing well-being support.
• Liaise with practice clinicians responsible for frailty regarding patients that are identified as needing ongoing support.
• Liaise with acute trusts, care homes, hospices, community and social care providers as required.

Record Keeping

• Keep accurate and up-to-date records of contact with patients, carers and professionals, including use of SystmOne to record patient contact on the medical record.
• Use accurate SNOMED codes to record patient contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomes.
• Manage reporting required and associated within the DES specifications for required services.
• Report case studies and outcomes to the PCN on a quarterly basis.

General Responsibilities

• Work as part of the team to seek feedback, continually improve the service and contribute to business planning.
• 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.
• 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.
• Attend and contribute to relevant meetings.
• Duties may vary from time to time, without changing the general character of the post or the level of responsibility.