Job summary Care Coordinators support patients in preparing for or in following-up clinical conversations they have with primary care professionals. Care Coordinators also support existing community groups to be accessible and sustainable and help the Social Prescribing team to assist people to start new community groups, where appropriate, working collaboratively with all local partners. The Care Coordinator will work as a key part of the Primary Care Network (PCN) multi-disciplinary team, helping PCNs to strengthen community and personal resilience and reduce health and wellbeing inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity, by increasing peoples active involvement with their local diverse communities. This role has been funded for 12 months to support Red House practice. The care Co-ordinator will lead a pilot working with families who are disengaged in healthcare, and have low activation which may impact the whole the whole family. Main duties of the job Proactively identify people to support their personalised care requirements, using the available decision support aids. Telephone triage all incoming referrals to bring together all of a persons identified care and support needs, and explore their options to meet these viaa single personalised care and support plan, or seamlessly refer cases, if necessary, to appropriate professionals. Help people to manage their needs, answering their queries and supporting them to make appointments or to take up training and employment, and to access appropriate benefits where eligible. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the Patient Activation Measure. 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 good quality information to help them make choices about their care, Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. Please see attached job description for further details About us Sunderland GP Alliance is a not-for-profit collaboration of GP practices in Sunderland. All GP Practices in Sunderland are members of the organisation, covering approximately 285,000 patients. The Alliance also runs three practices in Washington, South Hylton and New Silksworth. Formed in 2015, Sunderland GP Alliance is an organisation owned by the GP Practices of Sunderland, it exists to help GPs work collaboratively for the benefit of patients and staff. All GP practices in Sunderland are members of the organisation. The Alliance works on a not-for-profit basis, ensuring any surplus is reinvested back into better services for patients. Organisations such as ours help General Practice respond to the changing needs of the health system. Many of the services we provide cannot be delivered by individual GP surgeries. Our COVID vaccination programme, our community integrated team support and our enhanced access service are all good examples of this; In the enhanced access service only by working together with all the practices can we offer patients the convenience of appointments with members of the GP team on weekday evenings and during the day on weekends in locations across the city within their neighbourhoods. This is often referred to as federated working. Date posted 31 October 2024 Pay scheme Other Salary £27,003.42 a year Pro rata for part time Contract Fixed term Duration 12 months Working pattern Part-time Reference number U0012-24-0068 Job locations North East BIC Wearfield Sunderland Tyne and Wear SR5 2TA Red House Medical Centre 127 Renfrew Road Sunderland SR5 5PS Job description Job responsibilities Main Duties and Responsibilitie Proactively identify people to support their personalised care requirements, using the available decision support aids Telephone triage all incoming referrals to bring together all of a persons identified care and support needs, and explore their options to meet these via a single personalised care and support plan, or seamlessly refer cases, if necessary, to appropriate professionals. Help people to manage their needs, answering their queries and supporting them to make appointments or to take up training and employment, and to access appropriate benefits where eligible. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the Patient Activation Measure. 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 good quality information to help them make choices about their care, Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame To be the first point of contact for GP practices, MDT and Social Prescribing Link Workers, as well as a direct link for the wider system across the city. Support the identification of patients for inclusion in MDTs within PCNs. Support the collection of patient data for analysis of outcome measure for service interpretation and growth Role Specific Key Tasks Education Promote social prescribing across the PCN, Health & Social Care professionals and the wider system, including its role in self-management, addressing health inequalities and the wider determinants of health. Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health access and outcomes and enable a holistic approach to care. Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals. Referrals Receive and action referrals for social prescriptions via agreed systems. Manage and prioritise referrals appropriately. Redirect referrals, using the agreed protocols, to more appropriate Link workers or agencies. Be proactive in developing strong links with all local agencies to encourage referrals. Support referral agencies to provide appropriate information about the person they are referring. Provide appropriate monitoring and review of referrals received and feedback to referral agencies. Adhere to data protection legislation and data sharing agreements. Personalised Support Work collaboratively & be proactive in encouraging equality and inclusion, through connecting with diverse local communities, particularly those communities that statutory agencies may find hard to reach. Build trust and respect within the wider team, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on community assets. Be an engaging source of information about health, wellbeing and prevention approaches. Analyse data outcomes and identify what individuals expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing. Follow up with patients to ensure they are happy, able to engage, included and receiving good support. Support with patient queries where appointed Social Prescribing Link Worker is unavailable and provide cover during annual leave Undertake patient and provider surveys to support service development Community Asset Development Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing. Support community groups and VCSE organisations to receive referrals Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of diverse community groups and assets, who promote diversity and inclusion. Develop supportive relationships with local VCSE organisations, culturally appropriate community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. Work collectively with all local partners to ensure community groups are strong and sustainable Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision. Collaborative working As part of the PCN multi-disciplinary team, build close working relationships with staff in GP practices within the local PCN, giving information and feedback on social prescribing. Work with established VCSE organisations and existing Link Workers to provide a robust and consistent approach to our Sunderland people. Explore ways of working and share good practice and learning across all social prescribing roles within the system. Data Collection & Analysis Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives. Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing. Analyse types of referrals, cohorts and end points to support identification of gaps in provision and produce documentation for service interpretation. Proactively identify cohorts of patients, utilising close links with LA, PHE and GP Practices, that may benefit from accessing Social Prescribing Service Professional Development Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Service Development Seek regular feedback about the quality of the service and impact of social prescribing on referral agencies. Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning. Contribute to the development of policies and plans relating to equality, diversity and health inequalities. Leadership Support the social prescribing team in the development, delivery and education of social prescribing and health coaching, ensuring involvement where value can be added. Provide administrative and advisory support to the social prescribing team Demonstrate an understanding of ,and contribute to, the workplace vision Have a proven commitment to improve quality within limitations of service Monitor professional progress, and with the support of supervisor, develop clear plans to achieve goals and maintain high standards of work Promote diversity and equality within the workplace and wider community and shall lead by example Other Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner. Duties may vary from time to time, without changing the general character of the post or the level of responsibility. Job description Job responsibilities Main Duties and Responsibilitie Proactively identify people to support their personalised care requirements, using the available decision support aids Telephone triage all incoming referrals to bring together all of a persons identified care and support needs, and explore their options to meet these via a single personalised care and support plan, or seamlessly refer cases, if necessary, to appropriate professionals. Help people to manage their needs, answering their queries and supporting them to make appointments or to take up training and employment, and to access appropriate benefits where eligible. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the Patient Activation Measure. 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 good quality information to help them make choices about their care, Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame To be the first point of contact for GP practices, MDT and Social Prescribing Link Workers, as well as a direct link for the wider system across the city. Support the identification of patients for inclusion in MDTs within PCNs. Support the collection of patient data for analysis of outcome measure for service interpretation and growth Role Specific Key Tasks Education Promote social prescribing across the PCN, Health & Social Care professionals and the wider system, including its role in self-management, addressing health inequalities and the wider determinants of health. Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health access and outcomes and enable a holistic approach to care. Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals. Referrals Receive and action referrals for social prescriptions via agreed systems. Manage and prioritise referrals appropriately. Redirect referrals, using the agreed protocols, to more appropriate Link workers or agencies. Be proactive in developing strong links with all local agencies to encourage referrals. Support referral agencies to provide appropriate information about the person they are referring. Provide appropriate monitoring and review of referrals received and feedback to referral agencies. Adhere to data protection legislation and data sharing agreements. Personalised Support Work collaboratively & be proactive in encouraging equality and inclusion, through connecting with diverse local communities, particularly those communities that statutory agencies may find hard to reach. Build trust and respect within the wider team, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on community assets. Be an engaging source of information about health, wellbeing and prevention approaches. Analyse data outcomes and identify what individuals expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing. Follow up with patients to ensure they are happy, able to engage, included and receiving good support. Support with patient queries where appointed Social Prescribing Link Worker is unavailable and provide cover during annual leave Undertake patient and provider surveys to support service development Community Asset Development Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing. Support community groups and VCSE organisations to receive referrals Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of diverse community groups and assets, who promote diversity and inclusion. Develop supportive relationships with local VCSE organisations, culturally appropriate community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. Work collectively with all local partners to ensure community groups are strong and sustainable Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision. Collaborative working As part of the PCN multi-disciplinary team, build close working relationships with staff in GP practices within the local PCN, giving information and feedback on social prescribing. Work with established VCSE organisations and existing Link Workers to provide a robust and consistent approach to our Sunderland people. Explore ways of working and share good practice and learning across all social prescribing roles within the system. Data Collection & Analysis Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives. Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing. Analyse types of referrals, cohorts and end points to support identification of gaps in provision and produce documentation for service interpretation. Proactively identify cohorts of patients, utilising close links with LA, PHE and GP Practices, that may benefit from accessing Social Prescribing Service Professional Development Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Service Development Seek regular feedback about the quality of the service and impact of social prescribing on referral agencies. Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning. Contribute to the development of policies and plans relating to equality, diversity and health inequalities. Leadership Support the social prescribing team in the development, delivery and education of social prescribing and health coaching, ensuring involvement where value can be added. Provide administrative and advisory support to the social prescribing team Demonstrate an understanding of ,and contribute to, the workplace vision Have a proven commitment to improve quality within limitations of service Monitor professional progress, and with the support of supervisor, develop clear plans to achieve goals and maintain high standards of work Promote diversity and equality within the workplace and wider community and shall lead by example Other Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner. Duties may vary from time to time, without changing the general character of the post or the level of responsibility. Person Specification Qualifications Essential Demonstrable commitment to personal and professional development Proficient in the use of Microsoft Office applications. Able to provide a culturally sensitive service supporting people from all backgrounds and communities respecting lifestyle and diversity. Must be a car driver. Desirable Experience of working in general practice Knowledge of how the NHS works, primary care and PCN's. Experience Essential Excellent communication skills and an ability to engage successfully with a wide range of people at all levels. Experience of collecting and recording confidential information and data Ability to identify risk to self and others, Identifying and reporting safeguarding incidents. Ability to actively listen and empathise with people and provide personalised support in a non judgement way. Basic knowledge of long-term conditions and the complexities involved; medical, physical, emotional, and social. The ability to work calmly under pressure. The ability to adapt your leadership and management style to different situations. Experience of championing diversity and inclusion and promoting actions to make improvements to the experience of diverse groups Desirable Experience of working in a multi setting complex programme environment Experience of working in a community setting Extensive knowledge of local services within a Sunderland through either living or working within one of the wider Sunderland settings. Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work Ability to provide motivational coaching to support people's behaviour change. NVQ Level 3 in adult care, advanced level or equivalent qualifications or working towards. Motivation and Skills Essential Outstanding organisational skills, able to prioritise and work to deadlines. Work effectively and collaboratively as part of a team but also autonomously. Promote and maintain good working relationships with a variety of external partners. Keep accurate records of discussions and clearly replicate discussions in writing. Work on own initiative but within constraints of the role Understanding of and commitment to equality, diversity, and inclusion Ability to competently use technology and IT systems including word processing, email, and the internet to create simple personalised plans with individuals Ability to work across multiple sites in the Sunderland area. Confident and comfortable with difficult situations Patient, friendly and approachable Able to work under pressure and emotionally resilient. Ability to work flexible hours which may include occasional evenings or weekends with notice. Desirable Understanding the impact of economic and environmental factors on people's health and wellbeing Person Specification Qualifications Essential Demonstrable commitment to personal and professional development Proficient in the use of Microsoft Office applications. Able to provide a culturally sensitive service supporting people from all backgrounds and communities respecting lifestyle and diversity. Must be a car driver. Desirable Experience of working in general practice Knowledge of how the NHS works, primary care and PCN's. Experience Essential Excellent communication skills and an ability to engage successfully with a wide range of people at all levels. Experience of collecting and recording confidential information and data Ability to identify risk to self and others, Identifying and reporting safeguarding incidents. Ability to actively listen and empathise with people and provide personalised support in a non judgement way. Basic knowledge of long-term conditions and the complexities involved; medical, physical, emotional, and social. The ability to work calmly under pressure. The ability to adapt your leadership and management style to different situations. Experience of championing diversity and inclusion and promoting actions to make improvements to the experience of diverse groups Desirable Experience of working in a multi setting complex programme environment Experience of working in a community setting Extensive knowledge of local services within a Sunderland through either living or working within one of the wider Sunderland settings. Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work Ability to provide motivational coaching to support people's behaviour change. NVQ Level 3 in adult care, advanced level or equivalent qualifications or working towards. Motivation and Skills Essential Outstanding organisational skills, able to prioritise and work to deadlines. Work effectively and collaboratively as part of a team but also autonomously. Promote and maintain good working relationships with a variety of external partners. Keep accurate records of discussions and clearly replicate discussions in writing. Work on own initiative but within constraints of the role Understanding of and commitment to equality, diversity, and inclusion Ability to competently use technology and IT systems including word processing, email, and the internet to create simple personalised plans with individuals Ability to work across multiple sites in the Sunderland area. Confident and comfortable with difficult situations Patient, friendly and approachable Able to work under pressure and emotionally resilient. Ability to work flexible hours which may include occasional evenings or weekends with notice. Desirable Understanding the impact of economic and environmental factors on people's health and wellbeing 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. Certificate of Sponsorship Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab). From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab). Additional information 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. Certificate of Sponsorship Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab). From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab). Employer details Employer name Sunderland GP Alliance Address North East BIC Wearfield Sunderland Tyne and Wear SR5 2TA Employer's website https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)