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 peoples 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 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: o Regular contact with service supervisor o Refresher training sessions o Buddying with peers o Peer support sessions o 1:1 support from a practitioner with more health coaching experience o Action Learning Sets o e-learning to revisit or deepen training o On-going improvements to systems and processes Collect and collate service user experience and information that measures the impact of our service and support Key Tasks 1. Provide personalised support 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 the them, not whats 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 persons assets; Use a structured framework/model approach to support individuals and identify whats 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: o shared decision making with healthcare professionals; o effective engagement with personalised health and care plans; o proactive engagement with self-management education and peer support; o proactive engagement with social prescribing, connecting people to community-based activities which support their health and wellbeing if required; o proactive engagement with individually sourced activities and support 2. 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 1. 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 2. Supervision/Professional development 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. 3. Miscellaneous 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 others 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 Alliances 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 peoples 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 enhanced the teams 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. Recognise peoples 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.