Job summary The role will commence in April 25 Interviews will be held on Friday 28th February The role is part time 22.5 hours This is an exciting opportunity for the right person who wants to work supporting people by coordinating their health and social care services. Based in a single GP practice, 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 proactive, person-centred care planning, helping coordinate care, by bringing together the different specialists whose help that individual might need. This might involve a wide range of services, such as hospital care, community care, social care, housing and the voluntary sector. This 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. Supporting them to understand and manage their conditions and ensuring their changing needs are addressed. In line with support provided to other staff groups, there will be networking and training opportunities across the network, to support the development of the care co-ordinator role within the network, and wider primary care. Main duties of the job Work with 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 care plans by co-coordinating input from a range of different professionals and services Help patients to manage their needs through answering queries 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 Help patients to access personal health budgets where appropriate 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. Use practice level reports to identify suitable cohorts of patients to deliver personalised care Keep accurate and up to date records of contacts with patients and their carers/ families in the patients GP record and in their care plan As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager. About us We are two site GP Practice in North Somercotes and Manby.We cover a large part of Coastal East Lincolnshire from Tetney, to South Thoresby and from Louth and its surrounding villages to the coast. Our goal is to deliver high quality healthcare which is safe, effective, caring and responsive to the needs of our patients by following current best practice recommendations. Date posted 07 February 2025 Pay scheme Other Salary Depending on experience Contract Permanent Working pattern Part-time Reference number A2092-25-0000 Job locations Keeling Street North Somercotes Louth Lincolnshire LN11 7QU Job description Job 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 these care plans by co-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 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 wellbeing. 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 patients 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 patient 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 Stakeholder Relationships Work with the care home leads to identify skills, education and training needs and assist in the co-ordination and delivery of an agreed training programme Work as part of the wider holistic team to provide cover and support as necessary To link with partners to maximise the opportunities available to care home residents including access to on-line peer support and group programmes where the resident is unable to physically attend To work with our clinical and digital system colleagues to implement and operate technology solutions which may include wearables or equipment to enable self-taking of health diagnostics eg blood pressure, weight etc. Build and maintain relationships with care home staff and leads, together with members of the local support team including named GPs, pharmacist, community nursing team, therapists, dementia nurses etc. As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager. Job description Job 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 these care plans by co-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 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 wellbeing. 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 patients 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 patient 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 Stakeholder Relationships Work with the care home leads to identify skills, education and training needs and assist in the co-ordination and delivery of an agreed training programme Work as part of the wider holistic team to provide cover and support as necessary To link with partners to maximise the opportunities available to care home residents including access to on-line peer support and group programmes where the resident is unable to physically attend To work with our clinical and digital system colleagues to implement and operate technology solutions which may include wearables or equipment to enable self-taking of health diagnostics eg blood pressure, weight etc. Build and maintain relationships with care home staff and leads, together with members of the local support team including named GPs, pharmacist, community nursing team, therapists, dementia nurses etc. As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager. Person Specification Qualifications Essential Core level of Maths and English NVQ Level 3 in either Health & Social Care or Customer Service Experience Essential 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 Desirable Experience 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 people 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 Person Specification Qualifications Essential Core level of Maths and English NVQ Level 3 in either Health & Social Care or Customer Service Experience Essential 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 Desirable Experience 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 people 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 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 details Employer name Marsh Medical Practice Address Keeling Street North Somercotes Louth Lincolnshire LN11 7QU Employer's website https://www.marshmedicalpractice.com/ (Opens in a new tab)