We have an exciting and innovative new opportunity for a Care Co-ordinator working on the Proactive Care project for Bridgwater Bay Primary Care Network. The role involves working with a team of clinicians to enable people to live healthy independent lives and support active self-management and prevention. The candidate will possess excellent communication and organisation skills and have experience in a Health, Social Care or Educational background workplace. Candidates should have excellent IT skills and have an interest in collecting data from clinical systems to help develop the service and support the PCN Management Team.
The successful candidate will join our growing PCN workforce and support the delivery of care bringing together all the information about a patient's identified care and support needs and exploring options to meet these by identifying and signposting to appropriate clinicians. Patient needs will be discussed at MDT meetings with clear plans put into place to support people in our community.
Care coordinators play an important role within a PCN to proactively identify and work with people to provide coordination and navigation of care and support across health and care services.
They work closely with GPs and practice teams to support patients in the community, acting as a central point of contact to ensure appropriate support is made available to them; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
Main duties of the job
* Working with clinicians to provide support in neighbourhood areas with an emphasis on self-management and prevention of avoidable illness.
* Provide coordination and navigation for health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
* 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 and support PCN staff and patients to be more prepared to have shared decision making conversations.
* Support PCNs in developing communication channels between GPs and other agencies.
* Maintain records of referrals and interventions to enable monitoring and evaluation of the service.
* Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the patient's circumstances.
* Enable access to personalised care and support.
* Take referrals for individuals or proactively identify patients who could benefit from support through care coordination.
* Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patient's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
About us
Bridgwater Primary Care Network (PCN) is the largest PCN in Somerset with 9 GP practices, a health & wellbeing hub and a diverse population spread across town and rural locations.
As a PCN we are forward-thinking, innovative and driven to deliver the best patient care for our population. This includes health population management, and this role ties in with supporting that and tracking the improvements we can make to patients' lives.
In January 2023 we started an exciting joint venture with Somerset NHS Foundation Trust to open a Health and Wellbeing Hub at the old Victoria Park Medical Centre. This is a flagship hub, the first of its kind that will bring together Primary and Secondary care all under one roof to support the Bridgwater Bay community.
The focus of the hub is preventative care and supporting self-care management to the population.
Job responsibilities
Key roles and responsibilities
* Working with clinicians to provide support in neighbourhood areas with an emphasis on self-management and prevention of avoidable illness.
* Provide coordination and navigation for health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
* Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, and where appropriate, refer back to other health 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 and support PCN staff and patients to be more prepared to have shared decision making conversations.
* Carry out holistic assessments to identify patients in the community that could benefit from healthcare intervention. Aid patients in managing any long-term conditions they may have, supporting self-management and access to care.
* Support PCNs in developing communication channels between GPs and other agencies.
* Maintain records of referrals and interventions to enable monitoring and evaluation of the service.
* Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the patient's circumstances.
* Contribute to risk and impact assessments, monitoring and evaluations of the service.
* Work with commissioners, integrated locality teams and other agencies to support and further develop the role.
* Enable access to personalised care and support.
* Take referrals for individuals or proactively identify patients who could benefit from support through care coordination.
* Have a positive, empathetic and responsive conversation with the patient about their needs and when appropriate review personalised care and support plans.
* Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patient's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
* Help to transition seamlessly between services and support them to navigate through the health and care system.
* Refer onwards to appropriate healthcare professionals such as social prescribing link workers, voluntary sector workers and health and wellbeing coaches where required.
* Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the patient's care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
* Actively participate in multidisciplinary team meetings in the PCN and individual practices as and when appropriate.
* Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
* Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
* Work sensitively with patients to capture key information, while tracking the impact of care coordination on their health and wellbeing.
* Encourage patients to provide feedback and to share their stories about the impact of care coordination on their lives.
* Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
* Work with a named clinical point of contact for advice and support.
* Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required.
* Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
* Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each other's views and meeting regularly as a team.
* Act as a champion for personalised care and shared decision making within the PCN.
* Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
* Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning.
* Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities.
* Work in accordance with the practices and PCNs policies and procedures.
* Duties may vary from time to time without changing the general character of the post or the level of responsibility.
* Contribute to the wider aims and objectives of the PCN to improve and support primary care.
* To support in the delivery of the PCN Network DES, enhanced services and other service requirements on behalf of the PCN.
Person Specification
Qualifications
* High level of written and verbal communication skills.
* 5 GCSEs including English and Mathematics.
* Demonstratable commitment to professional and personal development.
* Ability to use Microsoft Office applications for example: Word, Excel, PowerPoint and Outlook is essential.
Experience
* KNOWLEDGE
* Knowledge and understanding of administrative elements surrounding personalised and support care planning.
* Understanding of, and commitment to, equality, diversity and inclusion.
* Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
* Strong organisational skills, including planning, prioritising, time management and record keeping.
* Knowledge of how the NHS works, including primary care and PCNs.
* Ability to recognise and work within limits of competence and seek advice when needed.
* Basic knowledge of long-term conditions and the complexities involved - medical, physical, emotional and social.
* Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
* EXPERIENCE
* Experience of administrative and IT systems.
* Experience of working within multi-professional team environments.
* Experience of supporting people, their families and carers in a related role.
* Experience of data collection and using tools to measure the impact of service.
Communication and Other
* COMMUNICATION SKILLS
* Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
* Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
* OTHER
* Access to own transport.
* Ability to travel across the locality.
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.
Full-time, Part-time, Job share, Flexible working.
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