Lincolnshire And District Medical Services (LADMS)
An exciting opportunity has become available for the 'right' person who wants to work supporting people by coordinating their health and social care services. Based predominantly in a single GP practice (although may be required to cover in other member practices on occasion) 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 new 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.
Job responsibilities
KEY RESPONSIBILITIES:
Working with patients:
* Work with individual patients, their families and carers, using a holistic approach, to identify their goals for care, and agree a personalised care and support plan for their care.
* Support delivery of those care plans by coordinating input from a range of different professionals and services, and helping patients and their carers/family to navigate across health and social care services.
* Work as part of the primary care team, coordinating care between GPs, Practice Nurses, Clinical Pharmacists, Social Prescribing Link Worker and Health and Wellbeing Coach.
* Help patients to manage their needs through answering queries, being a first point of contact in the practice, and by making and managing appointments.
* Support patients to utilise decision aids in preparation for a shared decision-making conversations and ensure that they, and their carers/family have access to good quality written and verbal information to help them make choices about their care.
* Support patients to take up training and employment where appropriate, and to access benefits where eligible.
* Help patients to access personal health budgets where appropriate.
* Make use of tools such as Patient Activation Measure when engaging with patients.
* Help patients to access self-management education courses, peer support or other interventions that support them in improving their health and well being.
* Undertake regular reviews of the personalised care and support plans developed with patients.
* Work in line with national best practice when developing personalised care and support plans.
* Work with patients over the phone, in person in the practice or, for those who are housebound, where necessary carry out home visits.
Administration:
* Use practice level reports to identify suitable cohorts of patients to deliver personalised care.
* Provide accurate and timely data to support audit and monitoring of the service, and any data returns as required by the ICB.
* Keep accurate and up to date records of contacts with patients and their carers/families in the patient's GP record and in their care plan.
* Follow up documentation required for care planning from other organisations, making use of Local Care Record where useful.
* Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations' communications and patients notes, and ensuring care packages are set up.
* Collect data on patients/carers for recognised outcome measures and document for service interpretation.
* Managing any necessary meetings to support care planning, identifying patients for discussion, organising the meeting and circulating required information beforehand as necessary.
* Ensure that meeting actions are recorded, disseminated and followed up in a timely way.
As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the postholder 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
* Core level of Maths and English.
* Relationship building skills.
* Empathy and patience.
* Qualifications in Health & Social Care and/or Customer Service.
Experience
* 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.
* 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
* Demonstrate an 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.
* Demonstrate ability to improve quality within the limitations of the service.
Personal Attributes
* 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.
* 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 name
Lincolnshire And District Medical Services (LADMS)
£10,085.40 a year Increase on successful probationary period.
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