Job summary
Wellspring Surgery is recruiting a Care Co-ordinator to support patients who use our Open Doors clinic. This clinic is for patients who experience multiple disadvantage and need extra support to access health services.
The current role also includes contacting patients with a recent cancer diagnosis.
You will be working closely with other members of the surgery team to support these client groups.
If you are a positive and clear communicator and are committed to supporting patients to achieve good health outcomes we look forward to hearing from you.
Main duties of the job
Care co-ordinators play an importantrole to proactively identify and work with people who needadditional support to access services. This includes people with multipledisadvantage and long-term conditions, providing coordination and navigation ofcare and support across health and care services.
This role will be specifically workingwith patients who have multiple and complex access needs to health services andfor patients who have received a recent cancer diagnosis.
They work closely with GPs and practiceteams to manage a caseload of patients, acting as a central point of contact toensure appropriate support is made available to them.
This is achieved by bringing togetherall the information about a persons identified care and support needs andexploring options to meet these within a single personalised care and supportplan, based on what matters to the person.
Care coordinators, review patientsneeds and help them access the services and support they require to understandand manage their own health and wellbeing, referring to social prescribing linkworkers and other professionals whereappropriate.
Care coordinators provide time and expertise to support people in clinical pathways, enabling them to be actively involved in managing their care and supported tomake choices that are right for them. Their aim is to help people improve theirquality of life.
About us
Wellspring Surgery proudly supports the community of Barton Hill in inner-city Bristol. We have a busy and friendly multidisciplinary team who are focused on supporting our patients and reducing health inequalities.
To find out more about the Surgery please visit:
Wellspring Surgery is part of the Bristol Inner City Primary Care Network:
Job description
Job responsibilities
Purpose of the role
Care co-ordinators play an important role within a PCN to proactively identify and work with people, who need additional support to access services. This includes people with multiple disadvantage and long-term conditions, providing coordination and navigation of care and support across health and care services.
This role will be specifically working with patients who have multiple and complex access needs to health services and for patients who have received a recent cancer diagnosis.
They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
Care coordinators, review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.
Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.
The successful candidate will be based in a local cluster of General Practices as part of Bristol Inner City Primary Care Network (PCN). They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.
This role is intended to become an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers 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.
Please note that the role of a care coordinator is not a clinical role.
Key responsibilities
Work with people, theirfamilies and carers to improve their understanding of the patients conditionand support them to develop and review personalised care and support plans tomanage their needs and achieve better healthcare outcomes.
Help people to managetheir needs through answering queries, making and managing appointments, andensuring that people have good quality written or verbal information to helpthem make choices about their care.
Support people tounderstand their level of knowledge, skills and confidence (their Activationlevel) when engaging with their health and wellbeing, including through the useof the Patient Activation Measure (PAM).
Assist people to accessself-management education courses, peer support or interventions that supportthem in their health and wellbeing and increase their Activation level.
Support people to take uptraining and employment, and to access appropriate benefits where eligible.
Provide coordination andnavigation for people and their carers across health and care services, workingclosely with the Surgery team, social prescribing link workers, health andwellbeing coaches, and other primary care professionals; helping to ensurepatients receive a joined up service and the most appropriate support.
Work collaboratively withGPs and other primary care professionals within the PCN to proactively identifyand manage a caseload, which may include patients with long-term healthconditions, and where appropriate, refer back to other health professionals withinthe PCN.
Support the coordinationand delivery of multidisciplinary teams with the PCN.
Raise awareness of how toidentify patients who may benefit from shared decision making and support PCNstaff and patients to be more prepared to have shared decision makingconversations.
Explore and assist peopleto access a personal health budget where appropriate.
Work with people, theirfamilies, carers and healthcare team members to encourage effectivehelp-seeking behaviours;
Support PCNs indeveloping communication channels between GPs, people and their families andcarers and other agencies;
Identify unpaid carersand help them access services to support them;
Conduct follow-ups oncommunications from out of hospital and in-patient services;
Maintain and code recordsof referrals and interventions, updating information to enable monitoring andevaluation of the service on EMIS;
Contribute to risk andimpact assessments, monitoring and evaluations of the service.
Key Tasks
1. Enable access to personalised careand support
a. Take referrals forindividuals or proactively identify people who could benefit from supportthrough care coordination;
b. Have a positive,empathetic and responsive conversation with the person and their family andcarer(s) about their needs;
c. Support people todevelop and implement personalised care and support plans;
d. Review and updatepersonalised care and support plans at regular intervals;
e. Ensure personalisedcare and support plans are communicated to the GP and any other professionalsinvolved in the persons care and uploaded to the relevant online care records,with activity recorded using the relevant SNOMED codes;
f. Where a personalhealth budget is an option, to work with the person and the local CCG team toprovide advice and support as appropriate.
2. Co-ordinate and integrate care
a. Help people transitionseamlessly between services and support them to navigate through the health andcare system;
b. Refer onwards tosocial prescribing link workers and health and wellbeing coaches whererequired;
c. Regularly liaise withthe range of multidisciplinary professionals and colleagues involved in thepersons care, facilitating a coordinated approach and ensuring everyone iskept up to date so that any issues or concerns can be appropriately addressedand supported;
d. Actively participatein multidisciplinary team meetings in the PCN as and when appropriate;
e. Identify when actionor additional support is needed, alerting a named clinical contact in additionto relevant professionals, and highlighting any safety concerns.
Person Specification
Qualifications
Essential
1. GCSE Grade A to C in English and Maths
Desirable
2. NVQ level 3 in adult care
3. 2 Day Personalised Care Institute accredited Care Co-ordinator training
Experience
Essential
4. Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
5. Experience of working within multi-professional team environments
6. Experience of supporting people, their families and carers in a related role
7. Experience of data collection and using tools to measure the impact of services
Desirable
8. Experience or training in personalised care and support planning
9. Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement