Job summary An exciting opportunity has arisen within Primary Care to work as a Care Coordinator at The Confederation, Hillingdon CIC. This role will be based at our Colne Union PCN. Care Coordinators play an important role within a PCN to proactively identify and work with people, including the 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 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 persons 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 Coordinators 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 Coordinators help people improve their quality of life. Main duties of the job We recognise the value that a PCN Care Coordinator can bring to our practices and our aim is to provide exemplary patient care; finding innovative solutions in general practice to deliver the best outcomes to our patients. We are seeking an enthusiastic and forward-thinking PCN Care Coordinator to join the ever growing team. The role will be to work within our network of GP Practices to provide a central co-ordination role for patient care planning. About us The Confederation, Hillingdon CIC works with general practice and other healthcare providers in Hillingdon to deliver high quality clinical services to patients. Our aim is to improve care for patients by working collaboratively across primary care and our partners as part of the Integrated Care Partnership. The Confederation team also work to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We are of the NHS but independent, innovative and transformational. General capacity across primary care is being expanded rapidly. The Confederation is determined to develop as an attractive place to work that provides rewarding roles and opportunities to grow in order to attract and retain great staff that in turn provides the highest quality care. Our Values: We work together to make a difference for patients We care enough to go the extra mile We support, trust, and empower We sincerely value each other We support Primary Care to own its destiny Date posted 05 November 2024 Pay scheme Other Salary £23,000 to £30,000 a year Dependent on Experience Contract Permanent Working pattern Full-time Reference number E0004-24-0057 Job locations 1A, Civic Centre, High Street Uxbridge Middlesex UB8 1UW Job description Job responsibilities Work with people, their families and carers, to improve their understanding of their condition. Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. 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. 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. Provide coordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, 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 people to be more prepared to have shared decision-making conversations. Take referrals or proactively identify people who could benefit from support through care coordination. Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs. Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance. 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. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly. Support people to develop and implement personalised care and support plans. Review and update personalised care and support plans at regular intervals. 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. Make and manage appointments for patients, related to primary care. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system. Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need. 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. Actively participate in multidisciplinary team meetings in the PCN. Identify when action or additional support is needed, alerting a named contact in addition to relevant professionals, and highlighting any safety concerns. Record what interventions are used to support people, and how people are developing on their health and care journey. Work with your supervising GP and/or line manager (if different) to undertake continual personal and professional development, taking an active part in reviewing yearly progress, and developing the roles and responsibilities and developing clear plans to achieve results within priorities set by others. Work with your supervising GP to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present. Involved in one-to-one meetings with line manager regularly to discuss targets and outcomes achieved. 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. 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. Adhere to organisational, practices and PCN policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. 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 their condition. Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. 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. 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. Provide coordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, 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 people to be more prepared to have shared decision-making conversations. Take referrals or proactively identify people who could benefit from support through care coordination. Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs. Increasing patients understanding of how to manage and improve health and wellbeing by offering advice and guidance. 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. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly. Support people to develop and implement personalised care and support plans. Review and update personalised care and support plans at regular intervals. 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. Make and manage appointments for patients, related to primary care. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system. Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need. 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. Actively participate in multidisciplinary team meetings in the PCN. Identify when action or additional support is needed, alerting a named contact in addition to relevant professionals, and highlighting any safety concerns. Record what interventions are used to support people, and how people are developing on their health and care journey. Work with your supervising GP and/or line manager (if different) to undertake continual personal and professional development, taking an active part in reviewing yearly progress, and developing the roles and responsibilities and developing clear plans to achieve results within priorities set by others. Work with your supervising GP to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present. Involved in one-to-one meetings with line manager regularly to discuss targets and outcomes achieved. 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. 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. Adhere to organisational, practices and PCN policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Contribute to the wider aims and objectives of the PCN to improve and support primary care. Person Specification Qualifications Essential GCSE in English and Math IT literacy Experience Essential Excellent communication skills. Good IT skills Good negotiating skills Empathy and good listening skills Desirable Experience in working in a healthcare setting Person Specification Qualifications Essential GCSE in English and Math IT literacy Experience Essential Excellent communication skills. Good IT skills Good negotiating skills Empathy and good listening skills Desirable Experience in working in a healthcare 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. Employer details Employer name The Confederation, Hillingdon CIC Address 1A, Civic Centre, High Street Uxbridge Middlesex UB8 1UW Employer's website https://www.theconfederationhillingdon.org.uk (Opens in a new tab)