Job details
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Pay
£26,530 - £29,114 a year
Job type
Permanent
Location
Stalybridge SK15 2AU
Full job description
Purpose of the role: Care co-ordinators play an important role within a PCN to proactively identify and work with people, including the frail, elderly, people with Learning Disability and those with long-term conditions, to provide co-ordination 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 people 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 co-ordinators could provide time, capacity and expertise to support people in preparing for, or following-up, clinical conversations.
Enabling them to be more actively involved in managing their care and supporting them to make choices that are right for them. Care co-ordinators help people improve their quality of life. The successful candidate will be based in Stalybridge, Dukinfield & Mossley PCN. They will be caring, dedicated, reliable, 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 an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers, Cancer Care Coordinator, Mental Health Nurse amongst other roles to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.
Key responsibilities
1. Work with people, their families and carers, to improve their understanding of their condition.
2. Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
3. Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
4. Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.
5. Provide co-ordination and navigation for people and their carers across health and care services.
6. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload.
7. Support the co-ordination and delivery of multidisciplinary teams with the PCN.
8. Raise awareness of how to identify patients who may benefit from shared decision making.
9. Explore and assist people to access a personal health budget where appropriate.
10. Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours.
11. Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies.
12. Identify carers and help them access services to support them.
13. Conduct follow-ups on communications from out of hospital and in-patient services.
14. Maintain records of referrals and interventions to enable monitoring and evaluation of the service.
15. Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the person's circumstances.
Supervision/professional development: 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.
Miscellaneous: Establish strong working relationships with GPs and practice teams and work collaboratively with other care co-ordinators, 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.
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