Care Coordinator Frailty Champion - Burnley West
We are looking to recruit to the post of Care Coordinator, Frailty Champion, to work within our Health & Wellbeing Team which is part of Burnley West Primary Care Network and Multidisciplinary Healthcare Team. You will support our member Practices by identifying patients who require a pro-active frailty assessment and also complete the assessments when identified patients are referred in to our Health & Wellbeing Team by our Practices and key Stakeholders.
The successful candidate will have good communication, negotiation and people management skills and act with compassion and integrity. They will have experience of using coaching approaches, frameworks and models or other helping strategies, for example, motivational interviewing.
The postholder will work with a diverse range of people from different cultural and social backgrounds. The ability to work confidently and effectively in a varied, and sometimes challenging environment is essential.
This is a vital role within the Primary Care Network and the post holder will provide advice and support for some of the most vulnerable people in the community, with long-term conditions. They will work closely with GP and practice teams to manage a caseload of patients, ensuring appropriate support is available to people, families and carers.
Main duties of the job
Job Purpose
A Care Coordinator Frailty Champion supports people to take pro-active steps to improve the way they manage their physical and mental health conditions, based on what matters to them.
The successful candidate will provide coordination and navigation for individuals and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
Proactively identify and work with a cohort of people to support their personalised care requirements.
Bring together all of a person's identified care and support needs and what matters to them; explore the options to address these in a single personalised care and support plan.
Help people to manage their needs, answering their queries and supporting them to make appointments.
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 high-quality health information to help them make choices about their care.
Support the coordination and delivery of multidisciplinary teams within PCNs.
About us
About Us
The East Lancashire Alliance is a network of 9 PCNs covering 48 GP practices covering a population of over 390,000 patients across East Lancashire. Patients are at the heart of everything we do and we pride ourselves in ensuring our patients feel safe, supported, communicated with and respected at a time when they may be feeling vulnerable.
The Alliance are proud to represent our member practices and to champion our Primary Care Partners, by working with local general practice and other system partners in the provision of patient centred, local healthcare services.
Each practice has a close-knit team of staff who collectively seek to improve the health of their patient populations.
Job responsibilities
Care Coordinators are a key part of the Primary Care Network (PCN) multidisciplinary team. They often work alongside Social Prescribing Link Workers and Health & Wellbeing Coaches to provide an all-encompassing approach to personalised care and promote and embed the personalised care approach across Primary Care Network(s).
Care Coordinators will have access to ongoing supervision, skills development, and support so they are able to further build their skills and experience within the role.
Please note that this role is a non-clinical role.
Key role requirements
Provide one-to-one support for people of the age of 50 or above with one or more health/care needs, supporting patients' needs based on what is important to them, with the aim of: improving people's knowledge, skills, confidence in managing their condition/s, empowering people to manage their own health and improve their health outcomes and support them in making changes relating to their health/social requirements.
Manage and prioritise a caseload, in accordance with the needs, priorities and support required by individuals in the caseload. It is vital that you have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when the person's needs are beyond the scope of the health and wellbeing coach role e.g. when there is a mental health need requiring the patient to be referred to an appropriately qualified practitioner.
Work as part of a multidisciplinary multi-agency team.
Ensure that GPs, practice nurses, practice pharmacists and other members of the primary care team understand the Health and Wellbeing Coach role, how to refer to them, and which patients may particularly benefit from health coaching.
Support local health, social care and voluntary sector professionals to make appropriate referrals to the service.
Attend and contribute to team, practice, and PCN meetings and events as required by the service.
Work flexibly, adapting to the needs of the service and client group while maintaining the integrity of the role.
Participate in regular supervision and continual learning. This may include, but is not limited to, any or all the following:
Regular contact with service supervisor, refresher training sessions, buddying with peers, peer support sessions, 1:1 support from a practitioner with more health coaching experience, e-learning to revisit or deepen training, ongoing improvements to systems and processes.
Collect and collate service user experience and information that measures the impact of our service and support.
Key Tasks
Meet people on a one-to-one face-to-face or by phone groups.
Give people time to tell their stories and focus on what matters to them, not what's the matter with them;
Build trust and respect with the person, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices;
Work from a strength-based approach focusing on a person's assets;
Use a structured framework/model approach to support individuals and identify what's important to them; set personal goals and appropriate steps; build skills and confidence to achieve goals; and use problem-solving to work through challenges;
Work with the principles of self-management to actively support:
shared decision making with healthcare professionals, effective engagement with personalised health and care plans, proactive engagement with self-management education and peer support, proactive engagement with social prescribing, connecting people to community-based activities which support their health and wellbeing if required, proactive engagement with individually sourced activities and support.
Referrals
As part of the PCN multidisciplinary team, build relationships with staff in GP practices within the local PCN, attending relevant multidisciplinary meetings, giving information and feedback on health coaching;
Be proactive in developing strong links with all local organisations and work in partnership with them to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals;
Provide referral organisations with regular updates including information on how to encourage appropriate referrals and seek regular feedback to improve on service delivery where appropriate.
Be proactive in encouraging equality and inclusion and case-finding, through self-referrals and connecting with all diverse local communities, particularly those communities that statutory bodies may find hard to reach.
General Tasks
Gathering and Reporting Information
Work sensitively with people, their families and carers to gather key information whilst supporting patients' health and wellbeing;
Encourage patients, their families and carers to provide feedback and to share their stories about the impact of support provided to them.
Support referral organisations to provide appropriate information about the person they are referring. Provide appropriate feedback to referral agencies about the people they referred.
Have access to relevant GPs to discuss patient-related concerns, and be supported to follow appropriate safeguarding procedures;
Know and adhere to organisational policies and procedures, including confidentiality, safeguarding, vulnerable adults, lone working, information governance, equality, diversity and inclusion training and health and safety.
Establish strong working relationships with GPs and practice teams and work collaboratively with Health and Wellbeing Coaches, other Care Coordinators and Social Prescribing Link Workers, supporting each other, respecting each other's views and meeting regularly as a team;
Act as a champion for frailty aged 50+ years and above as a part of the PCNs proactive frailty reviews.
Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner;
Identify opportunities and gaps in the service - and review risks and issues that could impact on service delivery - and provide feedback to continually improve the service and contribute to business planning;
Contribute to the development of policies and plans relating to equality, diversity and health inequalities;
Work in accordance with the practices and PCNs policies and procedures;
Contribute to the wider aims and objectives of the PCN to improve and support primary care.
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, staff, and other healthcare workers. They may also have access to information relating to any part of the business organisation. All such information from any source is to be regarded as strictly confidential.
Information relating to staff, patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with Alliance policies and procedures, and the protection of personal and sensitive data.
Health & Safety
The post-holder will assist in promoting and maintaining their own and others' health, safety and security as defined in the Alliance's Health & Safety Policy to include:
Identifying the risk involved in work activities and undertaking such activities in a way that manages those risks.
Ensure all accidents are reported and investigated, follow up action taken as necessary.
Maintain training in line with local policies.
Equality and Diversity
The post-holder will support the equality, diversity and rights of patients, carers and colleagues to include:
Acting in a way that recognizes the importance of people's rights, interpreting them in a way that is consistent with current legislation.
Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights.
Quality
The post-holder will strive to maintain quality 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 enhance the team's performance.
Work effectively with individuals in other agencies to meet patients' needs.
Effectively manage own time, workload and resources.
Contribution to the Implementation of Services
The post holder will:
Apply practice and PCN policies, standards and guidance.
Discuss with other members of the team how the policies, standards and guidelines will affect own work.
Participate in any audits where appropriate.
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.
Recognize people's needs for alternative methods of communication and respond accordingly.
This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.
Person Specification
Experience
* Experience of working within multi-professional team environments.
* Experience of supporting people, their families and carers in a related role.
* Experience or training in personalised care and support planning.
* Experience of data collection and using tools to measure the impact of services.
* Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
* Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement.
* 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).
Personal Qualities and Attributes
* Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
* Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity.
* Commitment to reducing health inequalities and proactively working to reach people from diverse communities.
* Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential.
* Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
* Ability to identify risk and assess/manage risk when working with individuals.
* Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner.
* Ability to work from an asset-based approach, building on existing community and personal assets.
* Ability to maintain effective working relationships and to promote collaborative practice with all colleagues.
* Ability to demonstrate personal accountability, emotional resilience and work well under pressure.
* Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
* High level of written and verbal communication skills.
* Ability to work flexibly and enthusiastically within a team or on own initiative.
* Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
Skills and Knowledge
* 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.
* Knowledge of how the NHS works, including primary care and PCNs.
* Knowledge of Safeguarding Vulnerable Adults policies and processes.
* Ability to recognise and work within limits of competence and seek advice when needed.
* Understanding of the needs of older people / adults with disabilities / long-term conditions particularly in relation to promoting their independence.
* Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social.
* Knowledge of the personalised care approach.
Other
* Meets DBS reference standards and criminal record checks.
* Willingness to work flexible hours when required to meet work demands.
* Access to own transport.
* Ability to travel across the locality on a regular basis.
* Proficient speaker of another language to aid communication with people in the community for whom English is a second language.
Qualifications
* NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards.
* Demonstrable commitment to professional and personal development is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute.
* Proficient in MS Office and web-based services.
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.
Depending on experience Band 4 ARRS - Agenda for Change Like
#J-18808-Ljbffr