This is a full-time role (35 hours per week) located across the four surgeries within the South Central Solihull Primary Care Network. Although you will be employed by Age UK Solihull, you will work closely with all surgery staff.
The role of Care Coordinator will be to identify and work with a defined cohort of patients and holistically bring together all their care and support needs, explore options to meet those needs and develop a single personalised care plan.
Main duties of the job
* Work alongside the GP practices to proactively identify and work with a cohort of patients to deliver personalised care, managing a caseload of patients.
* Develop a single personalised care and support plan with each patient through shared decision making enabling them to better manage their own care and support needs.
* Help people manage their needs through answering enquiries, making and managing appointments, and ensuring people have good written and verbal information to help them make choices about their care, using tools to understand an individual's knowledge and confidence in their own skills to manage their own health.
* Assist patients in accessing peer support and interventions that support them to take more control of their health and wellbeing.
* Provide coordination and navigation of patients and, where appropriate, their carers across health and social care services, working hand in hand with Social Prescribers, Health and Wellbeing Coaches, and liaising with wider health and social care professionals.
* Process relevant requests from hospital discharge letters.
* Have an awareness and understanding of when it is appropriate or necessary to refer people back to health professionals.
* Attend meetings as required.
* Adhere to the policies and processes of the PCN, NHS, and Age UK Solihull.
About us
Age UK Solihull is an independent, local charity and a Brand Partner of the national Age UK. We exist to be here for older people when they need our help and support. We are also the lead partner for the Solihull Community Advice Hubs, providing information, advice, and support to all adult residents of Solihull. Over 70 staff and 300 volunteers support our work.
Job responsibilities
Job title: Care Coordinator
Hours of Work: 35 per week
Salary: £24,136.00 pa
(The service will work flexibly to meet the needs of the PCN)
Location: GP Practices within the South Central Solihull PCN and, as necessary, Age UK Solihull offices at The Core.
Responsible to: Older Peoples Services Manager, Age UK Solihull (a Supervising Lead from the PCN will be appointed as will a Clinical Lead from each practice within the PCN)
Responsible for: N/A
Job purpose: To identify and work with a defined cohort of patients and holistically bring together all their care and support needs, explore options to meet those needs and develop a single personalised care plan. To support patients to make shared decisions and exercise choice based on what matters to them most. To work closely with primary care professionals and raise awareness within the PCN of shared decision making and decision support tools.
Key responsibilities:
* Work alongside the GP practices to proactively identify and work with a cohort of patients to deliver personalised care, managing a caseload of patients.
* Support patients to use shared decision-making tools.
* Take a holistic approach, based on the available options, a person's priorities, and the wider determinants of health.
* Develop a single personalised care and support plan with each patient through shared decision making enabling them to better manage their own care and support needs.
* Help people manage their needs through answering enquiries, making and managing appointments, and ensuring people have good written and verbal information to help them make choices about their care, using tools to understand an individual's knowledge and confidence in their own skills to manage their own health.
* Support patients to take up training and employment and access wider services through referrals to the Social Prescriber.
* Assist patients in accessing peer support and interventions that support them to take more control of their health and wellbeing.
* Explore the option of Personal Health Budgets for patients.
* Support the delivery and coordination of Multi-Disciplinary Team meetings.
* Provide coordination and navigation of patients and where appropriate their carers across health and social care services, working hand in hand with Social Prescribers, Health and Wellbeing Coaches, and liaising with wider health and social care professionals.
* Process relevant requests from hospital discharge letters.
* Have an awareness and understanding of when it is appropriate or necessary to refer people back to health professionals.
* Develop yourself and the role, undertaking the required training for the role and participating in service redesign.
* Contribute to effective information management and monitoring and reporting of data to support PCN DES targets in a timely manner.
* Attend meetings as required.
* Adhere to the policies and processes of the PCN, NHS, and Age UK Solihull.
* Work with the supervising Practice Manager and supervising Clinical Lead to access regular supervision.
* Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
* Any other duties commensurate with the grade of the post.
Person Specification
Experience
* Experience of supporting people, their families, and carers.
* Experience of data collection and using tools to measure the impact of services.
* Knowledge of the personalised care approach.
* Understanding of the wider determinants of health, including social, economic, and environmental factors and their impact on communities, individuals, their families, and carers.
* Knowledge of IT systems, including ability to use word processing skills, emails, and the internet to create simple plans and reports.
* Experience of administration.
* Knowledge of, and ability to work to, policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
* Experience of working directly in a health and/or social care setting.
* Local knowledge.
* Ability to use IT systems for data collection.
* Knowledge of how the NHS works, including primary care.
* Experience of supporting people with their mental health.
* Experience of partnership/collaborative working and of building relationships across a variety of organisations.
Additional Criteria - legal requirement
* A Disclosure and Barring check (DBS) will be required prior to appointment.
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.
#J-18808-Ljbffr