The role involves working veryclosely with the practices and the multidisciplinary team (MDT) within the PCN.The role is pivotal in ensuring all patients receive the best possible care andservice. The Care Coordinators role will support the clinical director andmember practices in coordinating all key activity including access to services,advice, and information, and ensuring health and care planning is timely,efficient, and patient-centered. The role will include supporting digitalinitiatives and includesresponsibilities for the co-ordination of the patients journey through primary care.
Main duties of the job
TheCare Coordinator responsibilities include but are not limited to thefollowing:
To work with the GPs and otherprimary care professionals within the Primary Care Network (PCN) to identifyand manage a caseload of patients who would benefit from support through carecoordination
Work with patients, theirfamilies and carers to improve their understanding of the patients conditionand support them to develop and review personalized care and support plans tomanage their needs and to achieve better healthcare outcomes.
Identity unpaid carers and helpthem access services to support them and place them on the carers register.
To support patients to utilisedecision aids, help create single personalised care and support plans, in linewith best practice.
To support the PCN in the delivery of the DES specifications, such astackling health inequalities through targeted work with specific groupsidentified through population health management.
To help people to manage theirneeds through answering queries, making, and managing appointments andensuring that people have good quality written or verbal information to helpthem make choices about their care
To provide coordination andnavigation with the aid of digital tools for people and their carers acrosshealth and care service.
To support the coordination anddelivery of MDTs within the PCN
About us
Havering Health is a Federation of 38* Practices that provide care for over 274,000*people. As one of Londons safest and greenest boroughs, Havering is ambitious tocontinually improve the quality of life for its residents.As an emerging Federation we already provide a range of community and primary careservices to our residents, as well as a number of support services including professionalstaff training across the practices.We are a core partner in Havering our local Integrated Care Partnership that coordinateshealth and social care provision in the Borough in order to improve wellbeing through thedelivery of person-centered care and self-help services across our community.Havering is a great place to live and work, within easy travelling distance to the center ofLondon. We have retail parks, leisure facilities, country parks plus the historic Romfordmarket on our doorstep and the Olympic park a short 15-minute train journey away.
Job responsibilities
Key Duties & Responsibilities:
TheCare Coordinator responsibilities include but are not limited to thefollowing:
To work with the GPs and otherprimary care professionals within the Primary Care Network (PCN) to identifyand manage a caseload of patients who would benefit from support through carecoordination
To work closely and in partnership with the Social Prescribing Link Worker andHealth and Well-being Coaches to assist people to access self-managementeducation courses, peer support, health coaching and other interventions thatsupport them in their health and wellbeing, and increase their levels ofknowledge, skills and confidence in managing their health.
Work with patients, theirfamilies and carers to improve their understanding of the patients conditionand support them to develop and review personalized care and support plans tomanage their needs and to achieve better healthcare outcomes.
Identity unpaid carers and helpthem access services to support them and place them on the carers register
To support patients to utilisedecision aids, help create single personalised care and support plans, in linewith best practice.
To support the PCN in the delivery of the DES specifications, such astackling health inequalities through targeted work with specific groupsidentified through population health management
To help people to manage theirneeds through answering queries, making, and managing appointments andensuring that people have good quality written or verbal information to helpthem make choices about their care
To provide coordination andnavigation with the aid of digital tools for people and their carers acrosshealth and care services
To support the coordination anddelivery of MDTs within the PCN
Collaborativeworking relationships
Works within the primary care team, contributingto leadership of service evaluation and research to promote quality improvementactivity.
Collaborates with multi-disciplinary PCNteam
Uses healthcare technologies to optimiseservice delivery, patients access, and continuity of care
Management
Demonstrates understanding of theimplications of national priorities for the team and/or service.
Uses resources effectively to managepatient treatment in line with local guidance and makes recommendations forchange where improvements can be made.
Follows professional and organisationalpolicies
Education, learningand development
It is the responsibility of the employee tocomply with all organisational and statutory requirements (eg. health andsafety, infection control, equality and diversity, confidentiality,safeguarding adults and children, information governance).
Engages in annual appraisal, developingobjectives to inform a Personal Development Plan, which may include 360-degreeappraisal and use of patient feedback.
Participate in teaching and training ofmedical, nursing, and all other practice staff.
Supports the practice staff and responds torequests for advice and assistance.
Complete all mandatory and statutorytraining required by the role.
Takes responsibility for personaldevelopment, learning and performance and maintain education through attendanceon any courses and/or study days necessary to ensure that professionaldevelopment requirements are met.
Undertakes additional training wherenecessary to provide enhanced services and participate in training programmesimplemented by the PCN/practices as part of this employment.
Understands and demonstrates thecharacteristics of a role model to members in the team and/or service.
Demonstrates an understanding of currenteducational policies relevant to working areas of practice and keeps up to datewith relevant clinical practice.
Quality
Under supervisionand support of GPs in the practice, the post-holder will strive to maintainquality within the practices, and will:
Participate in clinical governance activityand contribute to the improvement in quality of health outcomes through audit,risk management and Quality Improvement
Alerts other team members to concerns aboutrisk, quality, and safety
Participates in investigation of incidentsand events as required
Identifies, applies, and disseminatesresearch findings relating to own practice
Collects data for audit purposes and usesclinical audit to monitor quality in the service
Contributes to the effectiveness of theteam by reflecting on own and team activities and making suggestions on ways toimprove and enhance the teams performance
Works effectively with individuals in otheragencies to meet patients needs
Effectively manages own time, workload, andresources
Meets timescales/deadlines for audits andwritten returns to ensure that the Practice meets quality standards andreceives the designated funding.
Confidentiality
In the performance ofthe duties outlined in this Job Description, the post-holder will have accessto confidential information relating to patients and their carers, practicestaff and other healthcare workers. They may also have access to information relatingto the Company as a business organisation. All information is to be regarded asstrictly confidential.
Maintains confidentiality of anyinformation concerning patients in accordance with current policy oninformation governance.
Demonstrates respect for privacy andconfidentiality in all interactions with patients and the public.
Data Protection
This post has a requirement forconfidentiality. If you are required to obtain, process and/or use informationheld electronically you should do 'it in a fair and lawful way. You shouldhold data only for the specific registered purpose and not use or disclose itin any way incompatible with such a purpose. Data must only be disclosed toauthorised persons or organisations as instructed. Breaches of confidence inrelation to data will result in disciplinary action which may involvedismissal.
You must not at any time use the personaldata held by the organisation for any purpose other than practice business andthis must not be disclosed to a third party. If you are in any doubt regardingyour responsibilities under the Data Protection Act 2018 you must contact yourline manager or appropriate senior lead at the time.
Safeguarding adultsand children
The postholder has a duty to safeguard andpromote the welfare of vulnerable adults and children.
When adults or children and/or their carersuse primary care services, it is essential that all adult and child protectionconcerns are both recognised and acted on appropriately.
The postholder has a responsibility toensure they are familiar with and follow local policies in relation tosafeguarding vulnerable adults and that they follow the local child protectionprocedures and any supplementary guidance.
The postholder has a responsibility tosupport appropriate investigations either internally or externally.
To ensure the postholder is equipped tocarry out their duties effectively, they must also attend vulnerable adult andchild protection training and updates at the competency level appropriate tothe work they do and in accordance with the local vulnerable adult and childprotection training guidance.
Health & Safety
Assists in promotingand maintaining their own and others health, safety and security as defined inthe PCN Health & Safety Policy, to include:
Using personal security systems within theworkplace according to practice guidelines
Adhere to the guidance within the LoneWorkers policy, when making home visits
Identifying the risks involved in workactivities and undertaking such activities in a way that manages those risks
Making effective use of training to updateknowledge and skills
Using appropriate infection controlprocedures, maintaining work areas in a tidy and safe way and free from hazards
Complies with policies for infectioncontrol and hand hygiene to reduce the spread of healthcare-associatedinfections. For clinical staff with direct patient contact, this will includecompliance with clinical procedures and protocols, including uniform and dresscode, the use of personal protective equipment policy, safe procedures forusing aseptic techniques, and safe disposal of sharps
All staff are required to attend mandatorytraining in Infection Control and be compliant with all measures known to beeffective in reducing healthcare-associated infections
Equality andDiversity
Supports the equality,diversity, and rights of patients, carers and colleagues that includes:
Acting in a way that recognises theimportance of peoples rights, interpreting them in a way that is consistentwith practice procedures and policies, and current legislation
Respects the privacy, dignity, needs andbeliefs of patients, carers and colleagues
Flexibility
This job description is not intended to beexhaustive. The post-holder will be expected to adopt a flexible attitudetowards the duties outlined which may be subject to amendment at any time inconsultation with the post-holder and in line with the needs of theorganisation
The post holder may be required to fulfilother duties, as agreed with the practice manager /line manager to meet theneeds of the organisation. This will involve travel to other sites within theorganisation
Security
It is theresponsibility of all employees to work within the security policies andprocedures of the practices they work at to protect the patients, staff, andvisitors. This duty applies to the specific work area of the individual and thepractice in general. You are expected to wear ID and to sign in and out ofpractices you are working at
Person Specification
Qualifications
* GCSE grade A to C in English and Maths
Experience
* Must have some experience of working in general practice.
* Must have experience of either working in social care or acute community care
* Experience or understanding of co-ordinating an MDT in a health or social care setting
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.
£25,000 to £30,000 a yearThis depends on experience.
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