Job summary This role is to support the smooth co-ordination of patient care for one practice within the Primary Care Network for the benefit of our patients. Full time - 37.5 hours per week. Permanent position. Main duties of the job The Care Coordinator will be responsible for consulting with patients and determining their needs, developing care plans, coordinating patient-care services, educating them about their condition, empowering them to be independent whenever possible and working with the care team to evaluate interventions. About us Alliance for Better Care CIC is a GP Federation that unites 47 NHS GP practices across 12 Primary Care Networks in Sussex and Surrey. We support our Primary Care colleagues as well as their patients, to transform how healthcare is managed within the community. As a membership organisation, our focus is to work in partnership with our members and help them to improve the provision of General Practices in the local area. We work with and listen to our GP Practices, PCNs, Hospitals, Community Organisations and the Third Sector. These vital partnerships ensure that, together, we deliver a truly integrated approach that offers the support and expertise needed to effectively serve our communities Horsham Central Primary Care Network is a NHS Collaboration between two GP Practices Holbrook Surgery and Riverside Medical Practice - working together to provide enhanced access services. Our surgery teams work closely, sharing expertise and resources to develop new services. Our vision is to continue to improve the quality of care that we provide in alignment with the needs of our patient population. Date posted 08 November 2024 Pay scheme Other Salary £23,285.69 to £28,385.13 a year Contract Permanent Working pattern Full-time Reference number B0141-24-0080 Job locations Holbrook Surgery 9 Bartholomew Way Horsham West Sussex RH12 5JL Riverside Surgery 48 Worthing Road Horsham West Sussex RH12 1UD Job description Job responsibilities Key Responsibilities and Duties 1. To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence. 2. Use practice data to make informed decision, identify inequalities and initiate projects to improve services and the lives of our patients and community. 3. To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patients home if needed. 4. Liaise with Care Homes as necessary. MDT Coordination 1. Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting. 2. Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions. Managing a caseload 1. Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence. 2. Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions. 3. Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacy team, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews. 4. With the help of relevant clinical colleagues, develop a care plan to address patients personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare. 5. Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans. 6. Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans. 7. Check in on the patient regularly and evaluate and document their progress. Linking with other services 1. Signpost team members, service users and carers to relevant services including the PCN Social Prescribing Link Worker Service. 2. Liaise with the Social Prescriber and Mental Health Support Coordinator regarding patients that are identified as needing well-being support. 3. Liaise with practice clinicians responsible for frailty regarding patients that are identified as needing ongoing support. 4. Liaise with acute trusts, care homes, hospices, community and social care providers as required. Record Keeping 1. Keep accurate and up-to-date records of contact with patients, carers and professionals, including use of SystmOne to record patient contact on the medical record. 2. Use accurate SNOMED codes to record patient contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomes. 3. Manage reporting required and associated within the DES specifications for required services e.g IIF and other services such as EA. 4. Report case studies and outcomes to the PCN on a quarterly basis. General Responsibilities 1. Work as part of the team to seek feedback, continually improve the service and contribute to business planning. 2. 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. 3. Attend ongoing training and courses to keep abreast of new developments in health care. 4. Treat patients with empathy and respect and conduct oneself in a professional manner. 5. Attend and contribute to relevant meetings. 6. Duties may vary from time to time, without changing the general character of the post or the level of responsibility. Please see full Job Description for further information. Job description Job responsibilities Key Responsibilities and Duties 1. To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence. 2. Use practice data to make informed decision, identify inequalities and initiate projects to improve services and the lives of our patients and community. 3. To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patients home if needed. 4. Liaise with Care Homes as necessary. MDT Coordination 1. Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting. 2. Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions. Managing a caseload 1. Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence. 2. Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions. 3. Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacy team, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews. 4. With the help of relevant clinical colleagues, develop a care plan to address patients personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare. 5. Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans. 6. Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans. 7. Check in on the patient regularly and evaluate and document their progress. Linking with other services 1. Signpost team members, service users and carers to relevant services including the PCN Social Prescribing Link Worker Service. 2. Liaise with the Social Prescriber and Mental Health Support Coordinator regarding patients that are identified as needing well-being support. 3. Liaise with practice clinicians responsible for frailty regarding patients that are identified as needing ongoing support. 4. Liaise with acute trusts, care homes, hospices, community and social care providers as required. Record Keeping 1. Keep accurate and up-to-date records of contact with patients, carers and professionals, including use of SystmOne to record patient contact on the medical record. 2. Use accurate SNOMED codes to record patient contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomes. 3. Manage reporting required and associated within the DES specifications for required services e.g IIF and other services such as EA. 4. Report case studies and outcomes to the PCN on a quarterly basis. General Responsibilities 1. Work as part of the team to seek feedback, continually improve the service and contribute to business planning. 2. 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. 3. Attend ongoing training and courses to keep abreast of new developments in health care. 4. Treat patients with empathy and respect and conduct oneself in a professional manner. 5. Attend and contribute to relevant meetings. 6. Duties may vary from time to time, without changing the general character of the post or the level of responsibility. Please see full Job Description for further information. Person Specification Knowledge Essential Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety Skills and Abilities Essential Able to listen, empathise with people and provide person- centred support in a non-judgemental way. Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity. Committed to reducing health inequalities and proactively working to reach people from all communities. Able to support people in a way that inspires trust and confidence, motivating others to reach their potential. Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders. Able 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 link worker role e.g. when there is a mental health need requiring a qualified practitioner. Able to provide leadership and to finish work tasks. Able to maintain effective working relationships and to promote collaborative practice with all colleagues. Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues Demonstrates personal accountability, emotional resilience and works well under pressure. Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines. High level of written and oral communication skills. Desirable Excellent IT skills including Excel as well as knowledge of GP clinical systems, experience of data entry and coding. Behaviours and values Essential Able to work flexibly and enthusiastically within a team or on own initiative Qualifications Essential Demonstrable commitment to professional and personal development with a can do attitude Desirable NVQ Level 3, Advanced level or equivalent qualifications or working towards Training in motivational coaching and interviewing or equivalent experience Experience Desirable Experience of working directly in either the NHS or Adult Social Care Person Specification Knowledge Essential Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety Skills and Abilities Essential Able to listen, empathise with people and provide person- centred support in a non-judgemental way. Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity. Committed to reducing health inequalities and proactively working to reach people from all communities. Able to support people in a way that inspires trust and confidence, motivating others to reach their potential. Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders. Able 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 link worker role e.g. when there is a mental health need requiring a qualified practitioner. Able to provide leadership and to finish work tasks. Able to maintain effective working relationships and to promote collaborative practice with all colleagues. Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues Demonstrates personal accountability, emotional resilience and works well under pressure. Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines. High level of written and oral communication skills. Desirable Excellent IT skills including Excel as well as knowledge of GP clinical systems, experience of data entry and coding. Behaviours and values Essential Able to work flexibly and enthusiastically within a team or on own initiative Qualifications Essential Demonstrable commitment to professional and personal development with a can do attitude Desirable NVQ Level 3, Advanced level or equivalent qualifications or working towards Training in motivational coaching and interviewing or equivalent experience Experience Desirable Experience of working directly in either the NHS or Adult Social Care 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 Alliance for Better Care CIC Address Holbrook Surgery 9 Bartholomew Way Horsham West Sussex RH12 5JL Employer's website https://allianceforbettercare.org/ (Opens in a new tab)