• Job Description

  Req#: U0012-24-0022?language=en&page=123&sort=publicationDateDesc

  Job summary

  The Care Coordinator will work as part of a multidisciplinary team (MDT) within a GP practice to identify people in need of proactive support. This could be, for example, people who are frail or have multiple long-term physical and mental health conditions.

  They work with people individually, building trusting relationships and listening closely to what matters to them to develop a personalised care and support plan. This includes reviewing their needs and helping to connect them to the services and support they require within the practice or elsewhere, for example community and secondary services.

  Another key part of the role is to provide support for people who are preparing for clinical conversations with healthcare professionals or following up on those conversations, to ensure they can be actively involved in managing their care and supported to make choices that are right for them. Care coordinators work closely with GPs and practice teams to help manage caseloads. They act as a central point of contact so that appropriate support can be made available to individuals and their carers which helps them to manage their condition and addresses their needs.

  Main duties of the job

  The care coordinator is to play a key role in proactively identifying and working with people, including the frail/elderly with long-term conditions, to provide coordination and navigation of care and support across health and care services.

  The Practice Care coordinator will provide senior support to the practice team in targeting hard to reach groups with a focus on inequalities including Core20 Plus 5 groups andand patients.

  The Care Coordinator will review peoples identified needs and help to connect them to the services and support they require, whether within the practice or elsewhere for example, community and hospital-based services.

  Working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals' team to provide an all-encompassing approach to personalised care and enable people navigate through the health and care system.

  Identifying target areas such as long-term conditions, frailty, DES, QOF and IIF targets. Support practices in achieving their recall targets and providing an enhanced outreach service to those hard-to-reach groups.

  Identifying patients requiring proactive support i.e., hard to reach patients, high risk patients as identified in MDTs/practice meetings.

  Working with patients to improve their access to primary care services and comply with the requirements of the PCN Capacity and Access Improvement plan including the transformation elements of new triage processes.

  About us

  Sunderland GP Alliance is a not-for-profit collaboration of GP practices in Sunderland.

  All GP Practices in Sunderland are members of the organisation, covering approximately 285,000 patients.

  The Alliance also runs three practices in Washington, South Hylton and New Silksworth.

  Formed in 2015, Sunderland GP Alliance is an organisation owned by the GP Practices of Sunderland, it exists to help GPs work collaboratively for the benefit of patients and staff.

  All GP practices in Sunderland are members of the organisation. The Alliance works on a not-for-profit basis, ensuring any surplus is reinvested back into better services for patients.

  Organisations such as ours help General Practice respond to the changing needs of the health system. Many of the services we provide cannot be delivered by individual GP surgeries. Our COVID vaccination programme, our community integrated team support and our enhanced access service are all good examples of this; In the enhanced access service only by working together with all the practices can we offer patients the convenience of appointments with members of the GP team on weekday evenings and during the day on weekends in locations across the city within their neighbourhoods. This is often referred to as federated working.

  Date posted

  25 April 2024

  Pay scheme

  Other

  Salary

  £27,103.35 a year

  Contract

  Permanent

  Working pattern

  Full-time

  Reference number

  U0012-24-0022

  Job locations

  North East BIC

  Wearfield

  Sunderland

  Tyne and Wear

  SR5 2TA

  
  

  Silksworth Health Centre

  Silksworth Road

  Sunderland

  SR3 2AN

  
  

  Galleries Health Centre

  Washington Centre

  Washington

  Tyne And Wear

  NE38 7NQ

  
  

  Barmston Medical Centre

  Westerhope Road

  Washington

  Tyne And Wear

  NE38 8JF

  
  

  South Hylton Surgery

  2 Union Street

  South Hylton

  Sunderland

  SR4 0LS

  
  

  Job description

  Job responsibilities

  Main Duties and Responsibilities

  • Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
  • Support patients to utilise decision aids in preparation for a shared decision-making conversation.
  • Holistically bring together all 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.
  • 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, using tools to understand people's level of knowledge, confidence in skills in managing their own health.
  • 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.
  • Support the coordination and delivery of MDTs.
  • Scheduling patient treatments and co-ordinating the initial visit and follow-up visits
  • Co-ordination of reminder procedures. Diary management in liaison with practice staff. Setting up of specialist appointments, including letters and records, and follow-up on care and outcomes

  • Preparation of treatment plan and explanation of treatment plans to patients, and dealing with patient questions

  • Following up patient decisions on treatments where these are not initially taken up.
  • Participating in the administrative responsibilities of the practice team i.e., DES, QOF IIF targets
  • Ensuring accurate and legible notes of all consultations and treatments are recorded in patients and accurate completion of all necessary documentation associated with patient health care.
  • Attending and participating in meetings as required i.e., MDTs, practice meeting (DES, QOF and IIF target meetings)
  • Providing services for the PCN

  Safeguarding

  • To comply with local safeguarding processes for children and vulnerable individuals.

  Health and Safety

  • To comply with the Health and Safety at Work etc Act 1974
  • To take responsibility for his/her own health and safety and that of other persons who may be affected by his/her own acts or omissions.
  • Making effective use of training to update knowledge and skills.
  • Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.
  • Reporting potential risks identified.

  Equality and diversity

  The post-holder will support the equality, diversity and rights of patients, carers, and colleagues by:

  • Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures, policies, and current legislation.
  • Respecting the privacy, dignity, needs and beliefs of patients, carers, and colleagues.
  • Behaving in a manner which is welcoming.
  • Behaving in a manner that is non-judgmental and respects circumstances, feelings, priorities, and rights

  Risk Management and Clinical Governance

  • To work within the Clinical Governance Framework of the GP Practice, incorporating Risk Management and all other quality initiatives

  General

  • To undertake any other duties commensurate with the role, within the bounds of his/her own competence

  The post holder is expected to be flexible and accommodating, following consultation, in terms of any changes in the future.

  CONFIDENTIALITY

  • In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. All such information from any source is to be regarded as strictly confidential.
  • Information relating to patients, carers, colleagues, other healthcare workers or the business of the Alliance may only be divulged to authorized persons in accordance with the Alliances policies and procedures relating to confidentiality, and the protection of personal and sensitive data.

  Quality

  The post-holder will strive to maintain quality within the Alliance, and will:

  • Alert other team members to issues of quality and risk.
  • Assess own performance and take accountability for own actions, either directly or under supervision.
  • Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhanced the teams performance.
  • Work effectively with individuals in other agencies to meet patients needs.
  • Effectively manage own time, workload, and resources.
  • Communication
  • The post-holder should recognize the importance of effective communication within the team and will strive to:
  • Communicate effectively with other team members.
  • Communicate effectively with patients and carers.
  • Recognise peoples needs for alternative methods of communication and respond accordingly.

  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.

  Job description

  Job responsibilities

  Main Duties and Responsibilities

  • Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
  • Support patients to utilise decision aids in preparation for a shared decision-making conversation.
  • Holistically bring together all 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.
  • 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, using tools to understand people's level of knowledge, confidence in skills in managing their own health.
  • 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.
  • Support the coordination and delivery of MDTs.
  • Scheduling patient treatments and co-ordinating the initial visit and follow-up visits
  • Co-ordination of reminder procedures. Diary management in liaison with practice staff. Setting up of specialist appointments, including letters and records, and follow-up on care and outcomes

  • Preparation of treatment plan and explanation of treatment plans to patients, and dealing with patient questions

  • Following up patient decisions on treatments where these are not initially taken up.
  • Participating in the administrative responsibilities of the practice team i.e., DES, QOF IIF targets
  • Ensuring accurate and legible notes of all consultations and treatments are recorded in patients and accurate completion of all necessary documentation associated with patient health care.
  • Attending and participating in meetings as required i.e., MDTs, practice meeting (DES, QOF and IIF target meetings)
  • Providing services for the PCN

  Safeguarding

  • To comply with local safeguarding processes for children and vulnerable individuals.

  Health and Safety

  • To comply with the Health and Safety at Work etc Act 1974
  • To take responsibility for his/her own health and safety and that of other persons who may be affected by his/her own acts or omissions.
  • Making effective use of training to update knowledge and skills.
  • Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.
  • Reporting potential risks identified.

  Equality and diversity

  The post-holder will support the equality, diversity and rights of patients, carers, and colleagues by:

  • Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures, policies, and current legislation.
  • Respecting the privacy, dignity, needs and beliefs of patients, carers, and colleagues.
  • Behaving in a manner which is welcoming.
  • Behaving in a manner that is non-judgmental and respects circumstances, feelings, priorities, and rights

  Risk Management and Clinical Governance

  • To work within the Clinical Governance Framework of the GP Practice, incorporating Risk Management and all other quality initiatives

  General

  • To undertake any other duties commensurate with the role, within the bounds of his/her own competence

  The post holder is expected to be flexible and accommodating, following consultation, in terms of any changes in the future.

  CONFIDENTIALITY

  • In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. All such information from any source is to be regarded as strictly confidential.
  • Information relating to patients, carers, colleagues, other healthcare workers or the business of the Alliance may only be divulged to authorized persons in accordance with the Alliances policies and procedures relating to confidentiality, and the protection of personal and sensitive data.

  Quality

  The post-holder will strive to maintain quality within the Alliance, and will:

  • Alert other team members to issues of quality and risk.
  • Assess own performance and take accountability for own actions, either directly or under supervision.
  • Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhanced the teams performance.
  • Work effectively with individuals in other agencies to meet patients needs.
  • Effectively manage own time, workload, and resources.
  • Communication
  • The post-holder should recognize the importance of effective communication within the team and will strive to:
  • Communicate effectively with other team members.
  • Communicate effectively with patients and carers.
  • Recognise peoples needs for alternative methods of communication and respond accordingly.

  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.

  Person Specification

  Qualifications

  Essential

  • Demonstrable commitment to personal and professional development
  • Proficient in the use of Microsoft Office applications.
  • Able to provide a culturally sensitive service supporting people from all backgrounds and communities respecting lifestyle and diversity.
  • Must be a car driver.

  Desirable

  • Experience of working in general practice
  • Knowledge of how the NHS works, primary care and PCN's.

  Experience

  Essential

  • Excellent communication skills and an ability to engage successfully with a wide range of people at all levels.
  • Experience of collecting and recording confidential information and data
  • Ability to identify risk to self and others, Identifying and reporting safeguarding incidents.
  • Ability to actively listen and empathise with people and provide personalised support in a non judgement way.
  • Basic knowledge of long-term conditions and the complexities involved; medical, physical, emotional, and social.
  • The ability to work calmly under pressure.
  • The ability to adapt your leadership and management style to different situations.
  • Experience of championing diversity and inclusion and promoting actions to make improvements to the experience of diverse groups

  Desirable

  • Experience of working in a multi setting complex programme environment
  • Experience of working in a community setting
  • Extensive knowledge of local services within a Sunderland through either living or working within one of the wider Sunderland settings.
  • Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work
  • Ability to provide motivational coaching to support people's behaviour change.
  • NVQ Level 3 in adult care, advanced level or equivalent qualifications or working towards.

  Motivation and Skills

  Essential

  • Outstanding organisational skills, able to prioritise and work to deadlines.
  • Work effectively and collaboratively as part of a team but also autonomously.
  • Promote and maintain good working relationships with a variety of external partners.
  • Keep accurate records of discussions and clearly replicate discussions in writing.
  • Work on own initiative but within constraints of the role
  • Understanding of and commitment to equality, diversity, and inclusion
  • Ability to competently use technology and IT systems including word processing, email, and the internet to create simple personalised plans with individuals
  • Ability to work across multiple sites in the Sunderland area.
  • Confident and comfortable with difficult situations
  • Patient, friendly and approachable
  • Able to work under pressure and emotionally resilient.
  • Ability to work flexible hours which may include occasional evenings or weekends with notice.

  Desirable

  • Understanding the impact of economic and environmental factors on people's health and wellbeing

  Person Specification

  Qualifications

  Essential

  • Demonstrable commitment to personal and professional development
  • Proficient in the use of Microsoft Office applications.
  • Able to provide a culturally sensitive service supporting people from all backgrounds and communities respecting lifestyle and diversity.
  • Must be a car driver.

  Desirable

  • Experience of working in general practice
  • Knowledge of how the NHS works, primary care and PCN's.

  Experience

  Essential

  • Excellent communication skills and an ability to engage successfully with a wide range of people at all levels.
  • Experience of collecting and recording confidential information and data
  • Ability to identify risk to self and others, Identifying and reporting safeguarding incidents.
  • Ability to actively listen and empathise with people and provide personalised support in a non judgement way.
  • Basic knowledge of long-term conditions and the complexities involved; medical, physical, emotional, and social.
  • The ability to work calmly under pressure.
  • The ability to adapt your leadership and management style to different situations.
  • Experience of championing diversity and inclusion and promoting actions to make improvements to the experience of diverse groups

  Desirable

  • Experience of working in a multi setting complex programme environment
  • Experience of working in a community setting
  • Extensive knowledge of local services within a Sunderland through either living or working within one of the wider Sunderland settings.
  • Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work
  • Ability to provide motivational coaching to support people's behaviour change.
  • NVQ Level 3 in adult care, advanced level or equivalent qualifications or working towards.

  Motivation and Skills

  Essential

  • Outstanding organisational skills, able to prioritise and work to deadlines.
  • Work effectively and collaboratively as part of a team but also autonomously.
  • Promote and maintain good working relationships with a variety of external partners.
  • Keep accurate records of discussions and clearly replicate discussions in writing.
  • Work on own initiative but within constraints of the role
  • Understanding of and commitment to equality, diversity, and inclusion
  • Ability to competently use technology and IT systems including word processing, email, and the internet to create simple personalised plans with individuals
  • Ability to work across multiple sites in the Sunderland area.
  • Confident and comfortable with difficult situations
  • Patient, friendly and approachable
  • Able to work under pressure and emotionally resilient.
  • Ability to work flexible hours which may include occasional evenings or weekends with notice.

  Desirable

  • Understanding the impact of economic and environmental factors on people's health and wellbeing

  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.

  Certificate of Sponsorship

  Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

  From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

  Additional information

  Certificate of Sponsorship

  Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

  From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

  Employer details

  Employer name

  Sunderland GP Alliance

  Address

  North East BIC

  Wearfield

  Sunderland

  Tyne and Wear

  SR5 2TA

  
  

  Employer's website

  https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)

  Employer details

  Employer name

  Sunderland GP Alliance

  Address

  North East BIC

  Wearfield

  Sunderland

  Tyne and Wear

  SR5 2TA

  
  

  Employer's website

  https://www.sunderlandgpalliance.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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