An exciting opportunity has arisen for a Care Co-ordinator to develop a pioneering role within primary care. The role will provide co-ordination and navigation for people and their carers across health and care services. This role mainly focuses on working as a part of our Enhanced Care Home Scheme.
Care Co-ordinators provide extra time, capacity and expertise to support patients in preparing for or in following up clinical conversations that they have with primary care professionals, i.e., doctors, nurses, physiotherapists, physician associates, paramedics, etc. They provide co-ordination and navigation for people and their carers across a variety of settings, including care homes, where they will work with the Enhanced Care Home Scheme Team to proactively manage this cohort of patients.
The post holder will work closely with social prescribing link workers, health and wellbeing coaches, and other primary care roles. Their focus is on delivering a comprehensive model for personalised care, reflecting local priorities, health inequalities, and population health management risk stratification. They also support the coordination and delivery of MDTs within PCNs.
Main duties of the job
The role is varied and may include supporting self-management education, peer support, case management, and facilitating group consultations, as well as liaising with external stakeholders and professionals across Primary Care & Social Care, arranging, coordinating, and attending MDTs.
You will take an approach that is non-judgmental, based on strong communication and negotiation skills. You will support personal choice and positive risk-taking while ensuring that patients understand the accountability of their own actions and decisions. Your role and skills will support and encourage the prevention of developing further illness or the deterioration of existing long-term conditions.
When working with our local care homes, the role will focus on undertaking a personal care and support plan for each resident and signposting patient needs to fellow Enhanced Care Home Scheme Team members. Ensuring seamless service provision significantly decreases the risk of the patient deteriorating and thereby reduces the overall cost of care and the likelihood that additional interventions will be needed in future.
About us
Employment will be with OWLS CIC Ltd West Lancashire GP Federation, as a central function to the GP Practices and Primary Care Network (PCN) members.
OWLS CIC is a small GP-owned and led not-for-profit primary care organisation, run by GPs and health professionals.
OWLS was founded in the 90s by a small group of General Practitioners, with the main aim of ensuring high-quality out-of-hours services. In 2017, it transitioned to become a GP Federation to support and provide services for its practices and to offer a vehicle that local GPs had an opportunity to bid for and provide innovative primary care services in their local area. We are a not-for-profit organisation, which means that all the money we generate through service contracts is invested back into providing patient care.
Job responsibilities
Care Co-Ordinators will:
1. Work closely with practice and PCN healthcare roles, the PCC is to identify and work with a cohort of people to support their personalised care requirements, using any available decision support tools such as Patient Activation Measure (PAM), templates, and software.
2. Meet patients, patient carers, and family members to discuss their personalised care requirements, the services available to them, and the help they want.
3. Visit patients, checking on the care that they have received and documenting it accordingly.
4. Work with the care team to evaluate interventions and identify where and when further ones will be required.
5. Help people to manage their needs by answering their queries and supporting them in making appointments.
6. Support people to access appropriate benefits where eligible as well as taking up employment and training.
7. Assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools.
8. Provide patients with high-quality, easy-to-understand information to assist them in making choices about their care.
9. Support patients in understanding their level of knowledge, skills, and confidence (known as activation level) when participating in their health and well-being using, where appropriate, the PAM.
10. Liaise with other PCCs in other practices across the region and share best practice.
11. Assist patients to access self-management education courses, peer support, or interventions that support them in their health and well-being.
12. Where appropriate, assist patients to access personal health budgets.
13. Provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW).
14. Support in the delivery of enhanced services and other service requirements on behalf of the PCN.
15. Lead in the management of patient complaints and participate in the identification of any necessary learning brought about through clinical incidents and near-miss events.
16. Actively participate in the delivery of multi-disciplinary team (MDT) meetings within PCNs; responsible for preparatory admin, sending meeting invitations, and taking notes of meetings.
17. Undertake all mandatory training and induction programs.
18. Contribute to and embrace the spectrum of clinical governance.
19. Contribute to public health campaigns (e.g., flu clinics) through advice or direct care.
20. Liaise with professionals across Primary Care & Social Care and co-ordinate the PCN MDT meetings.
21. Collate all patients' identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice.
22. Promote Care Co-ordination, its role in self-management, addressing health inequalities and the wider determinants of health.
23. Raise awareness within the PCN of shared decision making and decision support tools and supporting people in shared decision-making conversations.
24. Engage with and support the new and evolving agendas and service requirements across the PCN, including our work with Care Homes residents and the need to proactively manage their care in an individualised way.
25. Undertake clinical observations to support the plans, as appropriate.
26. Build relationships with staff in the GP practices, attending relevant MDT meetings, giving information and feedback on health coaching.
27. Provide education and specialist expertise to fellow PCN staff, ensuring they are made aware of care co-ordination, health and well-being coaching and social prescribing services and support colleagues to improve their skills and understanding of personalised care, behavioural approaches, and ensuring consistency in the follow-up of people's goals where an MDT is involved.
This job description and the above areas of responsibility are an indication of the role and could be subject to change.
Person Specification
Qualifications
* Minimum English GCSE grade C or equivalent.
* Minimum Maths GCSE grade C or equivalent.
* Customer Care Qualification.
Experience
* Experience of working in a health care setting.
Skills and Knowledge
* Computer literate with extensive experience of Microsoft Word, Outlook, Excel, PowerPoint, and Access.
* Excellent written, interpersonal, and communication skills.
* Ability to prioritise and have a flexible approach to workflows.
* Strong focus on timely delivery of objectives and strong self-motivation.
* Ability to communicate at all levels.
* Active and empathetic listening.
* Ability to build trust and rapport.
* Professional behaviour at all times.
* Effective time management.
* Ability to work as a team member and autonomously.
* Strong analytical thinking and ability to handle multiple tasks concurrently.
* Ability to travel to locations across West Lancashire.
* Experience of working in a Primary Care setting, healthcare environment and/or public sector is desirable.
* Experience in working within a digital environment.
* Planning and organisational skills.
* Knowledge of the core concepts and principles of personalised care, shared decision making, patient activation, health behaviour change, self-efficacy, motivation and assets-based approaches.
* Shared agenda setting/collaborative goal setting/shared follow-up planning.
* Knowledge of personalised care.
Behaviours and Values
* Strives for safe, quality, effective and efficient service provision.
* Promotes open and honest dialogue, valuing individual differences, respect aspirations and commitments, and seeks to understand priorities, needs, abilities and limits.
* Aware of the impact of own behaviour on others.
* Leads by example and actively role models the NHS and L&SC TH Values in all work, fostering an inclusive culture with compassion and humanity.
* Interprets equality, diversity and rights in accordance with legislation, policies, procedures and good practice.
* Constructively challenges and accepts feedback from others.
* Maintains confidentiality at all times.
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.
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