The successful candidate will be based in a local cluster of General Practices which are part of Primary Care Sheffield GP Practices in the Darnall and Tinsley area. They will be caring, dedicated, reliable, and person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills.
They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families, and carers with high-quality support.
This role is intended to become an integral part of the multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN. There may be a need to work remotely depending on the requirements of the role.
This role will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers within the Frailty Team. The post holder will contribute to tackling inequalities in health and social care. An ethos of promotion of independence and partnership-working is integral to this post.
Main duties of the job
Primary Duties and Areas of Responsibility
* Work with people, their families, and carers to improve their understanding of the patients' condition and support and review.
* Help people manage their needs through answering queries and making and managing appointments.
* Assist people to access self-management education courses, peer support, and health coaching.
* Support people to take up training and employment.
* Provide coordination and navigation for people and their carers across health and care services.
* Work collaboratively with GPs and other primary care professionals within the PCN.
* Support the coordination and delivery of multidisciplinary teams with the PCN.
* Raise awareness of how to identify patients who may benefit from shared decision making.
* Support patients referred to ensure attendance at appointments.
* Support the Occupational Therapist in proactive case finding around frailty.
* Support practices to maintain their carers registers.
* Support the network in achieving targets.
* Coordinate and manage the administrative functions of MDT meetings.
* Take minutes of MDT meetings and disseminate and chase progress.
* Work with people, their families, carers, and healthcare team members to encourage effective help-seeking behaviours.
* Identify unpaid carers and help them access services to support them.
* Maintain records of referrals and interventions.
* Support practices to keep care records up to date.
* Contribute to risk and impact assessments.
* Help to streamline the social prescribing pathway.
About us
Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
This is achieved by bringing together all the information about a person's identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
Care coordinators review patients' needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.
Care coordinators could potentially provide time, capacity, and expertise to support people in preparing for or following up on clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.
The salary is £35,299 per annum (including on-costs).
Job responsibilities
The Care Coordinator will be based in a local cluster of General Practices which are part of Primary Care Sheffield GP Practices in the Darnall and Tinsley area.
Receive and collate patient identifiable information. Training and support will be given to enable the CC to manage this effectively.
Work with reception and administrative staff to run searches and identify patients.
Liaise with Social Prescribers and Community Support Workers to signpost team members, service users, and carers to relevant services.
Support the maintenance of IT-based information systems and ensure all records are completed in a timely manner.
To ensure the IT requirements for recording activity are adhered to in collaboration with other team members; support in dealing with the separate IT systems in the network will be provided, e.g., EMIS and Systm1.
Ensure all GP systems records are kept up to date.
Communication and collaborative working relationships
Demonstrates ability to work as a member of a team.
Is able to recognise personal limitations and refer to a more appropriate colleague when necessary.
Manage and prioritise workload on a daily basis and deal with competing demands.
Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.
Works with other stakeholders as needed for the collective benefit of patients including, but not limited to, patients, residents, GP Nurses, other practice staff, and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations for example Medicines Management Team.
Develop excellent working relationships with all partners and wider service networks including the voluntary sector, GP practices, hospitals, community pharmacists, and other stakeholders relevant to the role.
Communicate effectively with patients and their families, carers, other staff both internal and external, and members of the public.
Other responsibilities
To act at all times in an anti-discriminatory manner.
To be able to plan and respond to workload according to operational priorities.
To support the delivery of these functions across wider locality areas where necessary.
To undertake any training required in order to maintain competency including mandatory training.
To contribute to and work within a safe working environment.
The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures.
The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.
The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act and identify and report as necessary any untoward accident, incident, or potentially hazardous environment.
Communication
Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding.
Effectively use all methods of communication and be aware of and manage barriers to communication.
Provide information to patients, their carers, and/or relatives on behalf of the team.
Adhere to all aspects of confidentiality and pay due regard to General Data Protection Regulation requirements at all times.
Supporting Care Delivery
Be a point of liaison for patients and their families with all health and social care professionals including keeping everyone informed and updated.
Follow through with service users and others involved to ensure all services and care arrangements are in place.
Autonomy/Scope within Role
The post holder will be required to work within clearly defined organisational protocols, policies, and procedures.
Key Relationships
Key Working Relationships Internal
GPs, Occupational Therapy, and General Practice teams within the PCN.
PCS Practices Leadership team.
Key Working Relationships External
GPs from neighbouring PCNs.
Service providers.
Voluntary services.
Carers/relatives.
Health and Safety/Risk Management
* The post-holder must comply at all times with the organisation and Practices Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisation's Incident Reporting System.
The post-holder will comply with the Data Protection Act 1984, The General Data Protection Regulations 2018, and the Access to Health Records Act 1990.
The post-holder will comply with all necessary training requirements relevant to the role as identified by the organisation.
Equality and Diversity
* The post-holder must cooperate with all policies and procedures designed to ensure equality of employment. Co-workers, patients, and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion, etc.
Respect for Patient Confidentiality
* The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.
Special Working Conditions
* The post-holder is required to travel independently between practice sites where applicable, and to attend meetings hosted by other agencies. Car driver essential. You may be required to visit patients in their own homes or in a care home.
Job Description Agreement
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.
Person Specification
Qualifications
* NVQ level 2 or equivalent.
* A minimum of 2 years experience of the healthcare setting and/or social care setting or multi-disciplinary setting.
Experience
* Demonstrable commitment to professional and personal development is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute.
* Experience of working in a busy and demanding environment.
* Proficient in using Microsoft office packages.
* Experience of collating data and information.
* Experience in using clinical systems.
* Experience of working with an elderly population. Understanding of the needs of older people/adults with disabilities/long-term conditions particularly in relation to promoting their independence.
Knowledge and Understanding
* Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity.
* Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
* An understanding and knowledge of the workings of the NHS and the challenges it faces.
* Knowledge/familiarity of medical terminology.
Skills and Competencies
* Computer literate with an ability to use the required systems/office packages.
* Excellent communication skills, verbal and written, with the ability to adjust their communication style and content to suit the audience.
* Able to communicate with a wide variety of agencies.
* Can demonstrate ability to work under own initiative and as part of a team.
* Able to meet deadlines, work under pressure and balance priorities.
* Able to build and sustain relationships at all levels, actively involving stakeholders where appropriate.
* Ability to identify risk and assess/manage risk when working with individuals.
* Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies when what the person needs is beyond the scope of the care coordinator role.
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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