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 people's active involvement with their local diverse communities.
Main duties of the job
This role has been funded for 12 months to support Red House practice. The Care Coordinator will lead a pilot working with families who are disengaged in healthcare, and have low activation which may impact the whole family.
Individuals and their families are missing out on:
1. Chronic Disease reviews
2. Screening
About us
Sunderland GP Alliance began in 2015 and as a limited company we have grown to over 200 employees today. We are innovative in responding to the changing needs of a 21st century health care system. With a not-for-profit ethos, people are at the heart of everything we do. Whether it is a patient being seen at one of our GP practices or out of hours service, or the people at the heart of the Alliance who make it a great friendly place to work. We want people to realise their potential inside and outside of work which is why we support your development and offer 33 days holiday plus bank holidays.
Job responsibilities
Main Duties and Responsibilities
1. Proactively identify people to support their personalised care requirements, using the available decision support aids.
2. Telephone triage all incoming referrals to bring together all of a person's 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.
3. 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.
4. 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.
5. Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision making conversation.
6. Ensure that people have good quality information to help them make choices about their care.
7. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
8. 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.
9. 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.
10. 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.
11. Support the identification of patients for inclusion in MDTs within PCNs.
12. Support the collection of patient data for analysis of outcome measure for service interpretation and growth.
Person Specification
Qualifications
* Demonstrable commitment to personal and professional development.
* Proficient in the use of Microsoft Office applications.
Experience
* Experience of supporting people, their families and carers in a paid or unpaid capacity.
* Experience of working in a community setting.
* Experience of handling confidential information.
* Experience of collecting and recording information and data.
* Ability to identify risk to self and others, identifying and reporting safeguarding incidents.
* Experience of working in or with voluntary organisations or groups in a paid or unpaid capacity.
* Experience of working collaboratively with different organisations, building trust, confidence and partnerships.
* Extensive knowledge of local services within a Sunderland Locality 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.
Skills & Abilities
* Prioritise and work to deadlines.
* Work effectively and collaboratively as part of a team but also autonomously.
* High level and adaptable communication skills across a range of individuals of all ages, backgrounds and cultures with varying social and emotional needs.
* Understanding the impact of economic and environmental factors on people's health and wellbeing.
* 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 support the development of small voluntary led groups.
Disposition
* Ability to work across multiple sites in the Sunderland area.
* Provide motivational coaching with the ability to inspire trust and confidence.
* 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 evenings or weekends.
* Ability to actively listen, empathise with people and provide non-judgemental support.
* Ability to respect and value individual lifestyles, backgrounds and cultures.
Other
* Full, valid driving licence and use of own car.
* Meet Enhanced DBS and Criminal Record checks.
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.
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