Care Coordinator

at  Sunderland GP Alliance

Main Duties and Responsibilitie Proactively identify people to support their personalised care requirements, using the available decision support aids Telephone triage all incoming referrals to bring together all of a persons identified care and support needs, and explore their options to meet these via a single personalised care and support plan, or seamlessly refer cases, if necessary, to appropriate professionals. Help people to manage their needs, answering their queries and supporting them to make appointments or to take up training and employment, and to access appropriate benefits where eligible. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the Patient Activation Measure. Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision making conversation.
Ensure that people have good quality information to help them make choices about their care, Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame To be the first point of contact for GP practices, MDT and Social Prescribing Link Workers, as well as a direct link for the wider system across the city. Support the identification of patients for inclusion in MDTs within PCNs.
Support the collection of patient data for analysis of outcome measure for service interpretation and growth Role Specific Key Tasks Education Promote social prescribing across the PCN, Health & Social Care professionals and the wider system, including its role in self-management, addressing health inequalities and the wider determinants of health. Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health access and outcomes and enable a holistic approach to care. Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals. Referrals Receive and action referrals for social prescriptions via agreed systems.
Manage and prioritise referrals appropriately. Redirect referrals, using the agreed protocols, to more appropriate Link workers or agencies. Be proactive in developing strong links with all local agencies to encourage referrals. Support referral agencies to provide appropriate information about the person they are referring.
Provide appropriate monitoring and review of referrals received and feedback to referral agencies. Adhere to data protection legislation and data sharing agreements. Personalised Support Work collaboratively & be proactive in encouraging equality and inclusion, through connecting with diverse local communities, particularly those communities that statutory agencies may find hard to reach. Build trust and respect within the wider team, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices.
Work from a strength-based approach focusing on community assets. Be an engaging source of information about health, wellbeing and prevention approaches. Analyse data outcomes and identify what individuals 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. Follow up with patients to ensure they are happy, able to engage, included and receiving good support.
Support with patient queries where appointed Social Prescribing Link Worker is unavailable and provide cover during annual leave Undertake patient and provider surveys to support service development Community Asset Development Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing. Support community groups and VCSE organisations to receive referrals Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of diverse community groups and assets, who promote diversity and inclusion. Develop supportive relationships with local VCSE organisations, culturally appropriate community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. Work collectively with all local partners to ensure community groups are strong and sustainable Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision.
Collaborative working As part of the PCN multi-disciplinary team, build close working relationships with staff in GP practices within the local PCN, giving information and feedback on social prescribing. Work with established VCSE organisations and existing Link Workers to provide a robust and consistent approach to our Sunderland people. Explore ways of working and share good practice and learning across all social prescribing roles within the system. Data Collection & Analysis Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.
Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing. Analyse types of referrals, cohorts and end points to support identification of gaps in provision and produce documentation for service interpretation. Proactively identify cohorts of patients, utilising close links with LA, PHE and GP Practices, that may benefit from accessing Social Prescribing Service Professional Development Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
Service Development Seek regular feedback about the quality of the service and impact of social prescribing on referral agencies. 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. Leadership Support the social prescribing team in the development, delivery and education of social prescribing and health coaching, ensuring involvement where value can be added.
Provide administrative and advisory support to the social prescribing team Demonstrate an understanding of ,and contribute to, the workplace vision Have a proven commitment to improve quality within limitations of service Monitor professional progress, and with the support of supervisor, develop clear plans to achieve goals and maintain high standards of work Promote diversity and equality within the workplace and wider community and shall lead by example Other 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. Duties may vary from time to time, without changing the general character of the post or the level of responsibility

Please refer the Job description for details