Job summary
This is an exciting opportunity to join Derbyshire Dales Primary Care Network ( DDPCN ) working with our Acute Home Visiting Service (AHVS), also known as Team Up. Derbyshire DalesPCN is seeking a dedicated and self-motivated Care Co-ordinator to work alongsideand support a multi-disciplinary team, to provide care to our housebound andpatients residing in care or residential homes.
This is an excitingopportunity to be at the forefront of the delivery of our Team Up/AgeingWell model of care. The role will operate across the traditional health andsocial care organisational boundaries, including with our GP practice partners,Community Rapid Response services and Falls services, ambulance and out ofhours services to help clinically deliver the service on a day-to-day basis.The aim for the service is to ultimately provide a holistic approach to acuteon day/rapid response services, enhanced health in care homes and enhancedproactive care for older people with frailty and patients with multi-facetedhealth problems.
Early application submission is encouraged as these roles when advertised previously attracted a high number of applicants. DDPCN will close the advert if the desired application numbers are reached ahead of the closing date .
Main duties of the job
The Care Co-ordinator willbe part of the Acute Home Visiting Team (AHVT), who are responsible formanaging planned long-term care. The Care Co-ordinators are a pivotal role tothe AHVT and will be the interface between service users, families, carers,primary, community and secondary care, social care, out of hoursservices and voluntary organisations. You will also contribute to tacklinghealth inequalities in health and social care particularly regardingindividuals with long-term conditions and maintain IT based information systemsand take responsibility to produce performance data, analyse and report for theservice. You will be responsible for co-ordinating, integrating and deliveringsupport to patients, and ensure effective and synchronised care is available topatients, proactively identifying their personalised care needs.
About us
Derbyshire Dales PrimaryCare Network is a group of 7 forward thinking and progressive practices(population circa 50k) who have developed friendly and effective workingrelationships with each other. The Derbyshire Dales are a great place to liveand work. We have a mix of country towns and rural hamlets spread across alarge geographic area.
Your employerwould be Derbyshire Dales Primary Care Network Ltd, and you would be entitledto be part of the NHS pension scheme.
Job description
Job responsibilities
Key Duties Tasksand Responsibilities
Case Work Discussion
Overall responsibility for the regular multi-disciplinary teammeetings and the smooth running of integrated care within the teamsetting. The key role of the CareCo-ordinator will be to schedule regular AHVT meetings, manage the meetingagenda items and identifying key themes for discussion, circulating informationto the team in advance of the meeting.
Collate, analyse, and present data and information to the team.
Co-ordinate and manage the administrative functions of the AHVTmeetings.
Note any key changes and team agreements and actions required anddisseminate these to the team.
Manage the teams database to track case management, service userjourneys and outcomes, and undertake analysis of caseload information for audit,service evaluation, and performance management purposes, to be reported back tothe MDT and Team Up Clinical and Operational Leads.
Patient Identification
Receive and collate information from hospital admissions anddischarges, plus out of hours calls, ambulance conveyances, and social care,and present this to the AHVT.
Identify people with complex needs and new service users andpresent this information to the AHVT.
Signpost team members, service users, families, and carers torelevant services, referring as appropriate.
Contribute to assessment to identify a specific need, to maintainindependence in the place they call home (own home, residential or carehome). Attend visits as appropriate toact as chaperone or to facilitate non-clinical referrals.
Maintenance of IT based information systems and responsibility forkey performance data
To ensure the IT requirements for recording activity are adheredto in collaboration with other team members.
To analyse and provide agreed performance/activity data on behalfof the AHVT for monthly reporting to the Integrated Care Board, and to supportongoing evaluation and success of the service.
Communication and Relationships
Work closely with health and social care system partners to ensurereferrals into the service are received and managed, and to co-ordinatepersonalised care for the patients on the caseload.
Develop excellent working relationships with internal and externalstakeholders and communicate effectively with service users, families, carers,residential and care homes, AHVT members and other organisationalrepresentatives to ensure there is smooth access into the service, and toensure patients receive the input they need from other services as required.
Fulfil an intermediary role between administrative staff,clinicians, social workers, allied health professionals, community teams andmental health teams.
Maintain relevant systems for colleagues involved in care, to beable to access.
Communicate to the team and relevant organisations of any goodnews case management stories.
Refer complex cases to the AHVT via multi-disciplinary teammeetings.
Build networks within the scope of the role to raise awareness andidentify groups and services available within the community.
Raise any potential safeguarding concerns with the relevantclinicians within the team
Liaise with AHVT members to ensure any outstanding actionsrequired by team to follow-up/facilitate tests or treatment/onward referpatients to other services.
Produce accurate, contemporaneous, and complete records of patientcontact, consistent with legislation, policies, and procedures.
Understand own role and scope, work within this scope of practiceand identify how this may develop over time.
Supporting Care Delivery
Be a key point of contact for service users, families, carers,residential and care homes, ensure there is a key point of contact within theteam for all service users from a clinical perspective, and act as an advocatefor patients, families, and carers to support the assessment and identificationof specific needs to maintain independence in the community.
Prepare proactive care plans for appropriate patients.
Work with the clinical team to provide proactive care for healthpromotion and/or long-term condition monitoring and management.
Follow through actions identified by the AHVT including arrangingtests, referrals, signposting etc.
Follow through with service users and others involved to ensureall services/care arrangements are in place.
Provide welcome home calls after acute or community hospitalstays for individuals who are frequent flyers, have complex needs or are atrisk of readmission.
Delegate clearly and appropriately, adopting the principles ofsafe practice and assessment of competence.
Discuss, highlight, and work with the team to create opportunitiesto improve patient care.
Other Responsibilities
Manage and prioritise workload daily and deal with the competingdemands of the team.
Plan and respond to workload according to operational priorities.
Participate in the induction of new staff to the team as required.
Take part in regular performance appraisal.
Take responsibility for self-development on a continuous basis andundertake any training required to maintain competency including mandatorytraining.
Participate in audits/service evaluation and learning eventsnecessary to the team.
Use own initiative to follow up activities, facilitate smoothservice delivery for service users and to act as facilitator to ensure actionsrequired by the team are undertaken as appropriate.
At times, lead or contribute to the planning and delivery ofimprovement projects.
Participate in the maintenance ofquality governance systems and processes across the organisation and itsactivities.
Disseminate learning and informationgained to other team members to share good practice.
Assess own learning needs andundertake learning as appropriate.
The list of duties above is not exhaustive and is intended tooutline the main activities of the post holder.
Person Specification
Qualifications
Essential
1. ECDL or equivalent Diploma/HNC level (or relevant experience)
2. NVQ Level 2 Business Administration (or relevant experience)
3. Demonstrable commitment to professional and personal continuous development.
Desirable
4. Training in motivational coaching and interviewing or equivalent.
5. Knowledge of primary care IT Systems Qualified to NVQ level 2 in Health and Social Care.
Experience
Essential
6. Experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field (including unpaid work)
7. Experience of data collection and providing monitoring information to assess the impact of services.
8. Experience of partnership/collaborative working and of building relationships across a variety of organisations.
9. Experience of working with or in general practice.
10. Working in a multi-disciplinary setting where influence and negotiation is required.
11. Knowledge/familiarity with medical terminology.
Desirable
12. Experience in use of databases.
13. Vulnerable adults awareness.
14. Experience of care of the elderly or frail
15. Experience of using SystmOne
Skills and Knowledge
Essential
16. Knowledge of the personalised care approach.
17. Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails, and the internet to create simple plans and reports.
18. Creative problem solver and willing to search for hard-to-find information.
19. Meets DBS reference standards and has a clear criminal record in line with the law on spend and convictions.
20. Access to own transport and ability to travel across the locality on a regular basis.
21. Continued commitment to improve skills and ability in new areas of work.
Desirable
22. Knowledge of general practice clinical systems, such as, EMIS and SystmOne. Ability to read large amounts of information and extract the salient points.
23. Data analysis and reporting.