Job description

Job responsibilities

The Care Co-ordinator will work as an integral part of the PCNs multidisciplinary team (MDTs), working alongside the existing CVD Care Co-ordinator and with the Social Prescribers and Health and Wellbeing Coaches to provide an all-encompassing approach to personalised care, and promoting and embedding the personalised care approach across the PCN. They will be based within both Practices within it.

The post holder will:

1. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload of patients with long-term health conditions, specifically those people with Cardiovascular Disease (CVD) and where appropriate, refer back to other health professionals within the PCN. This will involve regularly running reports from our clinical systems i.e. EMIS.

2. Provide proactive support to the Practices CVD teams and the PCN to ensure achievement of the new CVD specific QOF targets

3. Participate in the daily and weekly Multi-Disciplinary Team (MDT) One Team meetings with the PCN team and community services if required.

4. Provide co-ordination 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 to help ensure patients receive a joined up service and the most appropriate support.

5. Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.

6. Ensure that allocated patients are able to access services available in the community both free and where charges apply - based on the Co-ordinators detailed knowledge of the relevant access arrangements, eligibility criteria and service content. To connect the services that already exists locally both statutory and voluntary, so that services wrap-around the patient.

7. 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. Refer onwards to social prescribing link workers and health and wellbeing coaches where required.

8. Assist people to access an assessment for Adult Social Care where appropriate and provide information in connection with personal budgets.

9. Conduct follow-ups on communications from out of hospital and in-patient services.

10. Maintain records of referrals and interventions to enable monitoring and evaluation of the service.

11. Support the PCN in developing communication channels between GPs, people and their families and carers and other agencies.

12. Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances.

13. Contribute to risk and impact assessments, monitoring and evaluations of the service.

14. Review and update personalised care and support plans at regular intervals and ensure these are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED (system) codes.

15. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations.

16. Take referrals for individuals or proactively identify people who could benefit from support through care co-ordination.

Please note that we use a number of IT tools, including development AI, and this requires an openness, enthusiasm and interest in technology.

Job responsibilities

The Care Co-ordinator will work as an integral part of the PCNs multidisciplinary team (MDTs), working alongside the existing CVD Care Co-ordinator and with the Social Prescribers and Health and Wellbeing Coaches to provide an all-encompassing approach to personalised care, and promoting and embedding the personalised care approach across the PCN. They will be based within both Practices within it.

The post holder will:

1. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload of patients with long-term health conditions, specifically those people with Cardiovascular Disease (CVD) and where appropriate, refer back to other health professionals within the PCN. This will involve regularly running reports from our clinical systems i.e. EMIS.

2. Provide proactive support to the Practices CVD teams and the PCN to ensure achievement of the new CVD specific QOF targets

3. Participate in the daily and weekly Multi-Disciplinary Team (MDT) One Team meetings with the PCN team and community services if required.

4. Provide co-ordination 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 to help ensure patients receive a joined up service and the most appropriate support.

5. Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.

6. Ensure that allocated patients are able to access services available in the community both free and where charges apply - based on the Co-ordinators detailed knowledge of the relevant access arrangements, eligibility criteria and service content. To connect the services that already exists locally both statutory and voluntary, so that services wrap-around the patient.

7. 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. Refer onwards to social prescribing link workers and health and wellbeing coaches where required.

8. Assist people to access an assessment for Adult Social Care where appropriate and provide information in connection with personal budgets.

9. Conduct follow-ups on communications from out of hospital and in-patient services.

10. Maintain records of referrals and interventions to enable monitoring and evaluation of the service.

11. Support the PCN in developing communication channels between GPs, people and their families and carers and other agencies.

12. Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances.

13. Contribute to risk and impact assessments, monitoring and evaluations of the service.

14. Review and update personalised care and support plans at regular intervals and ensure these are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED (system) codes.

15. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations.

16. Take referrals for individuals or proactively identify people who could benefit from support through care co-ordination.

Please note that we use a number of IT tools, including development AI, and this requires an openness, enthusiasm and interest in technology.

Person Specification

Knowledge and Skills

Essential

• Excellent communication skills (written and oral)
• Strong IT skills including competency in the use of Office and Outlook
• Clear, polite telephone manner
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving & analytical skills
• Ability to follow policy and procedure

Desirable

• EMIS (clinical system) user skills
• Understanding of clinical coding
• Knowledge of the personalised care approach
• Knowledge of how the NHS works, including primary care and PCNs
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes

Personal Qualities

Essential

• Polite and confident
• Flexible and cooperative
• Motivated
• Forward thinker
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure

Other requirements

Essential

• Disclosure Barring Service (DBS) check
• Access to own transport and ability to travel across the PCN on a regular basis

Desirable

• Flexibility to work outside of core office hours

Experience

Essential

• Experience of working in a health or social care setting in a support role in direct contact with people, families or carers (in a paid or voluntary capacity),particularly those patients with CVD
• Experience of working within multi-professional team environments
• Experience of data collection, running reports and using tools to measure the impact of services

Desirable

• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
• Experience or training in personalised care and support planning
• Experience of working with elderly or vulnerable people, including those with CVD, complying with best practice and relevant legislation
• Experience of supporting people, their families and carers in a related role, particularly those with CVD

Qualifications

Essential

• Qualifications
• Educated to GSCE or equivalent standard A-C /Grade 4 or above in English and Maths
• Demonstrable commitment to professional and personal development

Desirable

• A-Level standard /NVQ Level 3 in adult care - advanced level or equivalent

Knowledge and Skills

Essential

• Excellent communication skills (written and oral)
• Strong IT skills including competency in the use of Office and Outlook
• Clear, polite telephone manner
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers
• Understanding of, and commitment to, equality, diversity and inclusion
• Strong organisational skills, including planning, prioritising, time management and record keeping
• Basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving & analytical skills
• Ability to follow policy and procedure

Desirable

• EMIS (clinical system) user skills
• Understanding of clinical coding
• Knowledge of the personalised care approach
• Knowledge of how the NHS works, including primary care and PCNs
• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes

Personal Qualities

Essential

• Polite and confident
• Flexible and cooperative
• Motivated
• Forward thinker
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure

Other requirements

Essential

• Disclosure Barring Service (DBS) check
• Access to own transport and ability to travel across the PCN on a regular basis

Desirable

• Flexibility to work outside of core office hours

Experience

Essential

• Experience of working in a health or social care setting in a support role in direct contact with people, families or carers (in a paid or voluntary capacity),particularly those patients with CVD
• Experience of working within multi-professional team environments
• Experience of data collection, running reports and using tools to measure the impact of services

Desirable

• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
• Experience or training in personalised care and support planning
• Experience of working with elderly or vulnerable people, including those with CVD, complying with best practice and relevant legislation
• Experience of supporting people, their families and carers in a related role, particularly those with CVD

Qualifications

Essential

• Qualifications
• Educated to GSCE or equivalent standard A-C /Grade 4 or above in English and Maths
• Demonstrable commitment to professional and personal development

Desirable

• A-Level standard /NVQ Level 3 in adult care - advanced level or equivalent

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

Tadley Medical Partnership

Address

Holmwood Health Centre

Franklin Avenue

Tadley

Hampshire

RG26 4ER

Employer's website

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