• Job Description

  Req#: E0187-24-0005?language=en&page=94&sort=publicationDateDesc

  Job summary

  An exciting opportunity has become available for the 'right' person who wants to work supporting people predominantly in the Care home setting with their health and social care services. Based predominantly in the Fairfield Enterprise Centre, the care coordinator will be involved in supporting the clinical team to proactively identify and work with patients, including the frail/elderly and those with long-term conditions to provide pro-active, person-centred care planning, helping coordinate care by bringing together the different specialists whose help that individual might need. This may involve a wide range of services such as hospital care, community care, social care, housing and the voluntary sector.

  This role has been developed to support the delivery of better outcomes for patients living with multiple long-term conditions to help them improve the quality of their life, fostering self care, independence and patient choice. The care co-ordinator will be a key contact for such patients, helping them to navigate health and social care and supporting them to understand and manage their conditions as well as ensuring their changing needs are addressed.

  Main duties of the job

  The Care Coordinator's role will support the PCN leadership team and GPs in coordinating all key activity including improving access to services, providing advice and information, and ensuring health and care planning is timely, efficient, and patient-centred. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care.

  The successful candidate will have excellent and proven negotiation and communication skills and will have an understanding of primary care services & community health services.

  About us

  Meridian Medical Primary Care Network (PCN) is made up of the two practices situated in the town centre of Louth, consisting of East Lindsey Medical Group and James Street Family Practice, together with Tasburgh Lodge Surgery in Woodhall Spa and Marsh Medical Practice in North Somercotes. The PCN serves a population of approximately 38,000 patients.

  Close working relationships exist between the PCN and LADMS

  Lincolnshire & District Medical Services (LADMS) Ltd is a federation of GPs delivering primary medical services in Lincolnshire, predominantly in the East of the county. Our main contracts include GP Extended Access services, the Covid-19 vaccination programme and the provision of INR services along the East coast.

  Date posted

  08 April 2024

  Pay scheme

  Other

  Salary

  Depending on experience

  Contract

  Permanent

  Working pattern

  Full-time

  Reference number

  E0187-24-0005

  Job locations

  Fairfield Enterprise Centre

  Lincoln Way

  Fairfield Industrial Estate

  Louth

  Lincolnshire

  LN11 0LS

  
  

  Job description

  Job responsibilities

  JOB ROLES AND RESPONSIBILITIES

  Meridian Medical PCN has a number of care homes (residential and nursing or joint) with capacity to provide care for approximately 480 residents. These range in size from smaller units with less than 10 beds to homes with over 30 beds and include some supporting those living with dementia and /or complex physical health needs. The post holder will work as part of our local multi-disciplinary team to ensure that all those living in care homes are able to live and age well and, when the time comes, to meet their end of life care wishes. You will build relationships with care home leads and their staff and act as a point of contact for residents, families and professionals who visit care homes, such as MDT members and in-reach specialists.

  The Care Coordinators role will support the PCN leadership team and GPs in coordinating all key activity including improving access to services, providing advice and information, and ensuring health and care planning is timely, efficient, and patient-centred. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care.

  The successful candidate will have great negotiation and communication skills and will have an understanding of primary care services & community health services.

  The post holder will also be required to travel from practice to practice and to other venues during fulfilment of their duties.

  KEY RESPONSIBILITIES:

  Care planning

  Ensure every resident has a co-produced comprehensive care plan created within seven days of arriving as a resident

  Use provided templates and tools to undertake core assessment elements for inclusion in the care plan

  Holistically bring together all of a persons 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.

  Identify those elements of the care plan which require specialist input (pharmacist, dietician, nurse, medic etc.) and ensure that these are completed in timely manner

  Ensure end of life plans are correctly recorded and where appropriate have been shared with family members.

  Identify where technology can be utilised to support continued independence or to aid remote monitoring of health and wellbeing

  Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding

  Effectively use all methods of communication and be aware of and manage barriers to care

  Care home rounds and MDTs

  Overall responsibility for arranging the weekly PCN-led MDT meetings (including the weekly virtual Care Home (s) MDT

  Schedule the weekly MDT meetings

  Manage the meeting agenda items

  Identify the patients needing to be prioritised for review that week

  Ensure all new residents are reviewed in the MDT within four weeks of arrival

  Ensure all residents returning to the home after an acute hospital admission are reviewed by the MDT within seven days of return

  Circulate relevant information to MDT members in advance of the meeting

  Ensure actions from the MDT are recorded and care plans are correctly updated

  Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function

  Chase progress against actions and ensure follow-up where necessary

  Manage reporting required and associated within the PCN contract for Enhanced Health in Care Homes support.

  Stakeholder Relationships:

  Work with the care home leads to identify skills, education and training needs and assist in the co-ordination and delivery of an agreed training programme

  Work as part of the wider holistic team to provide cover and support as necessary

  To link with partners to maximise the opportunities available to care home residents including access to on-line peer support and group programmes where the resident is unable to physically attend

  To work with our clinical and digital system colleagues to implement and operate technology solutions which may include wearables or equipment to enable self-taking of health diagnostics eg blood pressure, weight etc.

  Build and maintain relationships with care home staff and leads, together with members of the local support team including named GPs, pharmacist, community nursing team, therapists, dementia nurses etc.

  As this is an evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager.

  The content of this job description will be reviewed regularly in the light of changing service requirements and any such changes will be discussed with the post holder.

  Job description

  Job responsibilities

  JOB ROLES AND RESPONSIBILITIES

  Meridian Medical PCN has a number of care homes (residential and nursing or joint) with capacity to provide care for approximately 480 residents. These range in size from smaller units with less than 10 beds to homes with over 30 beds and include some supporting those living with dementia and /or complex physical health needs. The post holder will work as part of our local multi-disciplinary team to ensure that all those living in care homes are able to live and age well and, when the time comes, to meet their end of life care wishes. You will build relationships with care home leads and their staff and act as a point of contact for residents, families and professionals who visit care homes, such as MDT members and in-reach specialists.

  The Care Coordinators role will support the PCN leadership team and GPs in coordinating all key activity including improving access to services, providing advice and information, and ensuring health and care planning is timely, efficient, and patient-centred. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care.

  The successful candidate will have great negotiation and communication skills and will have an understanding of primary care services & community health services.

  The post holder will also be required to travel from practice to practice and to other venues during fulfilment of their duties.

  KEY RESPONSIBILITIES:

  Care planning

  Ensure every resident has a co-produced comprehensive care plan created within seven days of arriving as a resident

  Use provided templates and tools to undertake core assessment elements for inclusion in the care plan

  Holistically bring together all of a persons 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.

  Identify those elements of the care plan which require specialist input (pharmacist, dietician, nurse, medic etc.) and ensure that these are completed in timely manner

  Ensure end of life plans are correctly recorded and where appropriate have been shared with family members.

  Identify where technology can be utilised to support continued independence or to aid remote monitoring of health and wellbeing

  Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding

  Effectively use all methods of communication and be aware of and manage barriers to care

  Care home rounds and MDTs

  Overall responsibility for arranging the weekly PCN-led MDT meetings (including the weekly virtual Care Home (s) MDT

  Schedule the weekly MDT meetings

  Manage the meeting agenda items

  Identify the patients needing to be prioritised for review that week

  Ensure all new residents are reviewed in the MDT within four weeks of arrival

  Ensure all residents returning to the home after an acute hospital admission are reviewed by the MDT within seven days of return

  Circulate relevant information to MDT members in advance of the meeting

  Ensure actions from the MDT are recorded and care plans are correctly updated

  Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function

  Chase progress against actions and ensure follow-up where necessary

  Manage reporting required and associated within the PCN contract for Enhanced Health in Care Homes support.

  Stakeholder Relationships:

  Work with the care home leads to identify skills, education and training needs and assist in the co-ordination and delivery of an agreed training programme

  Work as part of the wider holistic team to provide cover and support as necessary

  To link with partners to maximise the opportunities available to care home residents including access to on-line peer support and group programmes where the resident is unable to physically attend

  To work with our clinical and digital system colleagues to implement and operate technology solutions which may include wearables or equipment to enable self-taking of health diagnostics eg blood pressure, weight etc.

  Build and maintain relationships with care home staff and leads, together with members of the local support team including named GPs, pharmacist, community nursing team, therapists, dementia nurses etc.

  As this is an evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager.

  The content of this job description will be reviewed regularly in the light of changing service requirements and any such changes will be discussed with the post holder.

  Person Specification

  Qualifications

  Essential

  • Core level of Maths and English

  Desirable

  • NVQ Level 3 in either Health & Social Care or Customer Service

  Experience

  Essential

  • An understanding/experience of healthcare or care home provision.
  • Experience of preparing plans and reporting progress against these.
  • Experience of analysing and interpreting information and present results in a clear and concise manner.
  • Experience of administrative skills and robust record-keeping.

  Desirable

  • Experience of using SystmOne clinical system.
  • Understanding of wider healthcare delivery including roles of core MDT members and role of primary care.
  • Experience of providing advice/signposting to patients.
  • Experience of co-ordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
  • Experience of organising recurrent events.
  • Understanding/experience of using tools to create individualised plans.
  • Awareness of digital solutions to support independent living/remote healthcare monitoring.

  Skills and Knowledge

  Essential

  • Demonstrate and understanding of the Primary Care Network.
  • Awareness of clinical governance issues in primary care.
  • Ability to present plans, outcomes and learning to stakeholders.
  • Demonstrate commitment to professional and personal development.
  • Communication skills, both written and verbal.
  • Understanding of, and commitment to, equality, diversity and inclusion.

  Desirable

  • Demonstrate ability to improve quality within the limitations of the service.

  Personal Attributes

  Essential

  • Ability to work independently as well as collaboratively in a team.
  • Ability to work without direct supervision.
  • Committed to personal and team development.
  • Committed to person-centred, non-discriminatory practice.
  • Aware of requirements of confidentiality.
  • Forward thinking.
  • Excellent interpersonal skills and a confident approach.
  • Professional, approachable and respectful attitude towards others.
  • Able to maintain judgement under pressure.
  • Able to maintain motivations, drive and enthusiasm.
  • Flexible approach to work.
  • Ability to travel around the PCN patch if required to fulfil the role.

  Desirable

  • An ability to provide constructive feedback in a professional manner.
  • Recognises the role of other colleagues and their role to patient care.
  • Ability to recognise personal limitations and refer to more appropriate colleagues when necessary.

  Person Specification

  Qualifications

  Essential

  • Core level of Maths and English

  Desirable

  • NVQ Level 3 in either Health & Social Care or Customer Service

  Experience

  Essential

  • An understanding/experience of healthcare or care home provision.
  • Experience of preparing plans and reporting progress against these.
  • Experience of analysing and interpreting information and present results in a clear and concise manner.
  • Experience of administrative skills and robust record-keeping.

  Desirable

  • Experience of using SystmOne clinical system.
  • Understanding of wider healthcare delivery including roles of core MDT members and role of primary care.
  • Experience of providing advice/signposting to patients.
  • Experience of co-ordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
  • Experience of organising recurrent events.
  • Understanding/experience of using tools to create individualised plans.
  • Awareness of digital solutions to support independent living/remote healthcare monitoring.

  Skills and Knowledge

  Essential

  • Demonstrate and understanding of the Primary Care Network.
  • Awareness of clinical governance issues in primary care.
  • Ability to present plans, outcomes and learning to stakeholders.
  • Demonstrate commitment to professional and personal development.
  • Communication skills, both written and verbal.
  • Understanding of, and commitment to, equality, diversity and inclusion.

  Desirable

  • Demonstrate ability to improve quality within the limitations of the service.

  Personal Attributes

  Essential

  • Ability to work independently as well as collaboratively in a team.
  • Ability to work without direct supervision.
  • Committed to personal and team development.
  • Committed to person-centred, non-discriminatory practice.
  • Aware of requirements of confidentiality.
  • Forward thinking.
  • Excellent interpersonal skills and a confident approach.
  • Professional, approachable and respectful attitude towards others.
  • Able to maintain judgement under pressure.
  • Able to maintain motivations, drive and enthusiasm.
  • Flexible approach to work.
  • Ability to travel around the PCN patch if required to fulfil the role.

  Desirable

  • An ability to provide constructive feedback in a professional manner.
  • Recognises the role of other colleagues and their role to patient care.
  • Ability to recognise personal limitations and refer to more appropriate colleagues when necessary.

  Disclosure and Barring Service Check

  This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

  Employer details

  Employer name

  Lincolnshire And District Medical Services (LADMS)

  Address

  Fairfield Enterprise Centre

  Lincoln Way

  Fairfield Industrial Estate

  Louth

  Lincolnshire

  LN11 0LS

  
  

  Employer's website

  http://www.ladms.co.uk/ (Opens in a new tab)

  Employer details

  Employer name

  Lincolnshire And District Medical Services (LADMS)

  Address

  Fairfield Enterprise Centre

  Lincoln Way

  Fairfield Industrial Estate

  Louth

  Lincolnshire

  LN11 0LS

  
  

  Employer's website

  http://www.ladms.co.uk/ (Opens in a new tab)

• About the company

  National Health Service (NHS) is the umbrella term for the publicly-funded healthcare systems of the United Kingdom (UK). The founding principles were that services should be comprehensive, universal and free at the point of delivery—a health service based on clinical need, not ability to pay. Each service provides a comprehensive range of health services, free at the point of use for people ordinarily resident in the United Kingdom apart from dental treatment and optical care.

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