Job summary This role is 20 hours per week. Care coordinators play an important role within a PCN to proactively identify and work with all people, including children & young adult, 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, acting as a central point of contact to ensure appropriate support is made available to patients and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. 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 will work closely with the practice teams across the PCN to assist in coordinating mass vaccination programmes, ensuring appropriate patients are invited, and relevant volunteers are coordinated. There may be a need to work remotely depending on the requirements of the role. Please note that the role of a care coordinator is not a clinical role. Main duties of the job Work with people, their families and carers to improve their understanding of the patients condition & support them to develop personalized care & support plans to manage their needs & achieve better healthcare outcomes. Help people to manage their needs through answering queries, making & managing appointments & ensuring that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching & other interventions that support them in their health & wellbeing & increase their levels of knowledge, skills & confidence in managing their health. Support people to take up training & employment & to access appropriate benefits where eligible. Provide coordination & navigation for people & their carers across health & care services, working closely with social prescribing link workers, health & wellbeing coaches & other primary care professionals. Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances. About us Chippenham, Corsham and Box PCN is an enthusiastic, dynamic and friendly PCN made up of 5 GP surgeries, serving 64,000 patients. We are constantly striving to improve patient pathways and health care outcomes and we are developing innovative ways of working more closely together. As our PCN grows, we will be employing more professionals listing the in the PCN Additional Roles Reimbursement Scheme in the coming months and years. You will be supported by an experienced and dedicated Social Prescribing Team Leader and PCN Manager. Benefits: Company Pension Scheme Cycle to work scheme Care First - Free mental health and wellbeing services Continuing professional development Free Parking Date posted 17 October 2024 Pay scheme Other Salary £11,930 a year Contract Permanent Working pattern Part-time Reference number M0052-24-0010 Job locations Hathaway Surgery 32 New Road Chippenham Wiltshire SN15 1HP Job description Job responsibilities Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalized care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. 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. Support people to take up training and employment, and to access appropriate benefits where eligible; for example, through referral to social prescribing link workers. Provide coordination and navigation for people and their carers across 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. Enable access to personalised care and support a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination. b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs. c. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance. d. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them. e. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly. f. Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register g. Support people to develop and implement personalised care and support plans; h. Review and update personalised care and support plans at regular intervals; i. Undertake telephone assessments, home visits and face to face appointments. j. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes. Coordinate and integrate care a. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations b. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system; c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required; d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons 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; e. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate; f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. g. Record what interventions are used to support people, and how people are developing on their health and care journey, h. 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; i. Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing; j. Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives; k. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. Professional development a. Work with a named point of contact for advice and support. b. 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; c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Miscellaneous a. 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 others views and meeting regularly as a team b. Act as a champion for personalised care and shared decision making within the PCN c. 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 d. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning e. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities f. Work in accordance with the practices and PCNs policies and procedures g. Contribute to the wider aims and objectives of the PCN to improve and support primary care. Job description Job responsibilities Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalized care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. 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. Support people to take up training and employment, and to access appropriate benefits where eligible; for example, through referral to social prescribing link workers. Provide coordination and navigation for people and their carers across 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. Enable access to personalised care and support a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination. b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs. c. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance. d. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them. e. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly. f. Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register g. Support people to develop and implement personalised care and support plans; h. Review and update personalised care and support plans at regular intervals; i. Undertake telephone assessments, home visits and face to face appointments. j. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes. Coordinate and integrate care a. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations b. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system; c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required; d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons 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; e. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate; f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. g. Record what interventions are used to support people, and how people are developing on their health and care journey, h. 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; i. Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing; j. Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives; k. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. Professional development a. Work with a named point of contact for advice and support. b. 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; c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Miscellaneous a. 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 others views and meeting regularly as a team b. Act as a champion for personalised care and shared decision making within the PCN c. 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 d. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning e. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities f. Work in accordance with the practices and PCNs policies and procedures g. Contribute to the wider aims and objectives of the PCN to improve and support primary care. Person Specification Knowledge and Skills Essential 1) Ability to actively listen, empathise with people and provide personalised support in a non-judgmental way. 2) Ability to communicate effectively, both verbally and in writing with people, their families, carers, community groups, partner agencies and stakeholders. 3) Ability to maintain effective working relationships and to promote collaborate practice with all colleagues 4) Ability to work flexibly and enthusiastically within a team or on own initiative 5) Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers. 6) Meets DBS reference standards and criminal record checks 7) Access to own transport and the ability to travel across the locality on a regular basis Desirable 1) Health and Social Care Qualification 2) Ability to provide motivational coaching to support peoples behaviour change 3) Experience of working directly in a care coordinator role, adult health, children and young adults and social care, learning support or public health improvement 4) Experience or training in personalised care and support planning 5) Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation 6) Knowledge of Safeguarding Children and Vulnerable Adult policies and processes 7) Proficient speaker of another language to aid communication with people in the community for whom English is a second language Person Specification Knowledge and Skills Essential 1) Ability to actively listen, empathise with people and provide personalised support in a non-judgmental way. 2) Ability to communicate effectively, both verbally and in writing with people, their families, carers, community groups, partner agencies and stakeholders. 3) Ability to maintain effective working relationships and to promote collaborate practice with all colleagues 4) Ability to work flexibly and enthusiastically within a team or on own initiative 5) Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers. 6) Meets DBS reference standards and criminal record checks 7) Access to own transport and the ability to travel across the locality on a regular basis Desirable 1) Health and Social Care Qualification 2) Ability to provide motivational coaching to support peoples behaviour change 3) Experience of working directly in a care coordinator role, adult health, children and young adults and social care, learning support or public health improvement 4) Experience or training in personalised care and support planning 5) Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation 6) Knowledge of Safeguarding Children and Vulnerable Adult policies and processes 7) Proficient speaker of another language to aid communication with people in the community for whom English is a second language 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 Chippenham, Corsham & Box Primary Care Network Address Hathaway Surgery 32 New Road Chippenham Wiltshire SN15 1HP Employer's website https://www.hathawaysurgery.co.uk/chippenham-corsham-box-primary-care-network/ (Opens in a new tab)