Job summary Care coordinators play an important role within a practice and the wider PCN to proactively identify and work with people, including care home residents, the frail/elderly, people with learning disabilities/dementia and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. We are a friendly, forward-thinking and highly supportive training Practice in West Sussex. Offer a relaxed and friendly working environment in two purpose built buildings close to both the local beaches and South Downs National Park. We have a strong and stable partnership and have a dedicated team of highly skilled clinicians and non clinical members of staff. The advertised role is to replace one of our team who has chosen to further develop their career, and we are looking for someone motivated and keen to join our ever growing workforce. Main duties of the job Care Coordinators 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 them and their carers. They focus on what matters to patients and support them to understand and manage their condition, ensuring their changing needs are addressed. Care coordinators review patients needs, help them access the services and support they require to understand and manage their own health and wellbeing and work alongside other personalised care roles care coordinators, social prescribing link workers and health and wellbeing coaches to provide an all encompassing approach to personalised care. About us Avisford Medical Group, is a busy surgery situated in dual sites at Yapton and Middleton-on-Sea. We are a team of 48 experienced clinical and non clinical members all striving to give our 12,500 population the best possible care Date posted 30 January 2025 Pay scheme Other Salary Depending on experience I Contract Permanent Working pattern Full-time, Part-time, Flexible working Reference number A3921-25-0002 Job locations North End Road Yapton Arundel West Sussex BN18 0DU Middleton Medical Centre Shrubbs Drive Bognor Regis West Sussex PO227SR Job description Job responsibilities Coordination Duties Improve the care frail patients receive by coordinating the delivery of their care, proactively identifying unmet care needs and preventing unnecessary hospital admissions. Work with clinical professionals and patients to create care plans for frail patients. Ensure that all patients on the learning disability and dementia register receive an annual review in accordance with protocols. Liaise with the learning disability and dementia lead in each Practice to ensure that timely care is received as needed, clinical records are updated and annual review documents are up to date. Provide coordination support for patients to navigate health care services and expedite referrals, where necessary, to providers such as Proactive care, Care Home Matrons, Wheelchair Services, Community Nurses, Eyes and Ear Tests, SaLT, OT or Physio, Dementia Services. Document end of life in accordance with protocol and attend Practice GSF meetings, linking in with the Echo team, where required. Coordinate annual Structured Medication Reviews, SMR, with lead clinicians and MOCH Pharmacists. Refer to PCN personal care role workers, social prescribers and MIND wellbeing workers, where a patient is identified as potentially benefitting from this service. Support the Practice in achieving its Quality and Outcome Frameworks and other DES or LES specifications. Monitor referrals to ensure tasks are completed and care is delivered by keeping in regular contact with patients and their representatives. Help people to transition seamlessly between services and support them to navigate through the health and care system, liaising directly with multiple agencies to coordinate care for patients. 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. Review and update personalised care and support plans at regular intervals. Assist with the coordination of annual Flu and Covid vaccines programmes, gaining consent from patients or their representatives as appropriate, running searches to help with planning and entering data on the clinical system. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities. Work in accordance with the Practices and PCNs policies and procedures. Multidisciplinary Working Support the clinical and social care professionals in coordinating all key activity, including access to services, Multidisciplinary Team meetings, advice and information and ensuring health and care planning is timely, efficient and patient-centred. Support the setting up, coordination and management of regular multidisciplinary hub meetings, including but not limited to, Frailty and Palliative care, to ensure a smooth and coordinated approach, especially where multiple agencies are involved. Develop and coordinate the integrated care team hub, taking responsibility for a caseload of patients. Ensure regular and consistent communication with referrers regarding patient progress and any complications or guidance suggested by the MDT. Work with other Care Coordinators to develop knowledge of local services and teams, supporting and assisting each other through sharing of knowledge and good practice. Maintain and develop engagement with all Practice staff and encourage best practice. Act as a champion for personalised care and shared decision-making within the PCN. Identify opportunities and gaps in the service and contribute to continuous improvements to the service and business planning. Attend bi-weekly proactive care team meetings. Attend the PCN Board meetings, as required, to provide updates on EHiCH work and any other relevant information. Attend Practice meetings, when requested. Care Home Specific Duties Organise a weekly/bi-weekly ward round for each care home, as required by the allocated Practice, to obtain relevant information, such as new hospital attendances, falls, medication and updates regarding residents approaching end of life. Ensure all updated information gathered from the ward round is documented on the patients clinical record. Book appointments for care home residents on the clinical system, as required. Discuss personalised care for care home residents with patients, their families and the care home staff, ensuring the personalised care and support plans are recorded on the clinical system and the relevant template is completed. Gather appropriate information to record on ReSPECT forms. Discuss the hospital discharges for care home residents with patients, their relatives and the care home, as appropriate, ensuring the care plan is updated. Align the collection of new patient data/new patient checks with the requirements of the care home sector, using the new Care Home Patient Form, ensuring all information is entered onto the clinical system. Organise monthly care homes education meetings to discuss key topics including, but not limited to, ReSPECT Forms, Proxy Access, New Care Home Resident forms, Covid or flu vaccinations and consent. Coordinate annual structured Medication reviews with Care Home Matrons. Carry out any of the above coordinator duties in relation specifically to care home residents. Accountability The above list of duties is not exhaustive and may be subject to change, as deemed necessary. Job description Job responsibilities Coordination Duties Improve the care frail patients receive by coordinating the delivery of their care, proactively identifying unmet care needs and preventing unnecessary hospital admissions. Work with clinical professionals and patients to create care plans for frail patients. Ensure that all patients on the learning disability and dementia register receive an annual review in accordance with protocols. Liaise with the learning disability and dementia lead in each Practice to ensure that timely care is received as needed, clinical records are updated and annual review documents are up to date. Provide coordination support for patients to navigate health care services and expedite referrals, where necessary, to providers such as Proactive care, Care Home Matrons, Wheelchair Services, Community Nurses, Eyes and Ear Tests, SaLT, OT or Physio, Dementia Services. Document end of life in accordance with protocol and attend Practice GSF meetings, linking in with the Echo team, where required. Coordinate annual Structured Medication Reviews, SMR, with lead clinicians and MOCH Pharmacists. Refer to PCN personal care role workers, social prescribers and MIND wellbeing workers, where a patient is identified as potentially benefitting from this service. Support the Practice in achieving its Quality and Outcome Frameworks and other DES or LES specifications. Monitor referrals to ensure tasks are completed and care is delivered by keeping in regular contact with patients and their representatives. Help people to transition seamlessly between services and support them to navigate through the health and care system, liaising directly with multiple agencies to coordinate care for patients. 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. Review and update personalised care and support plans at regular intervals. Assist with the coordination of annual Flu and Covid vaccines programmes, gaining consent from patients or their representatives as appropriate, running searches to help with planning and entering data on the clinical system. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities. Work in accordance with the Practices and PCNs policies and procedures. Multidisciplinary Working Support the clinical and social care professionals in coordinating all key activity, including access to services, Multidisciplinary Team meetings, advice and information and ensuring health and care planning is timely, efficient and patient-centred. Support the setting up, coordination and management of regular multidisciplinary hub meetings, including but not limited to, Frailty and Palliative care, to ensure a smooth and coordinated approach, especially where multiple agencies are involved. Develop and coordinate the integrated care team hub, taking responsibility for a caseload of patients. Ensure regular and consistent communication with referrers regarding patient progress and any complications or guidance suggested by the MDT. Work with other Care Coordinators to develop knowledge of local services and teams, supporting and assisting each other through sharing of knowledge and good practice. Maintain and develop engagement with all Practice staff and encourage best practice. Act as a champion for personalised care and shared decision-making within the PCN. Identify opportunities and gaps in the service and contribute to continuous improvements to the service and business planning. Attend bi-weekly proactive care team meetings. Attend the PCN Board meetings, as required, to provide updates on EHiCH work and any other relevant information. Attend Practice meetings, when requested. Care Home Specific Duties Organise a weekly/bi-weekly ward round for each care home, as required by the allocated Practice, to obtain relevant information, such as new hospital attendances, falls, medication and updates regarding residents approaching end of life. Ensure all updated information gathered from the ward round is documented on the patients clinical record. Book appointments for care home residents on the clinical system, as required. Discuss personalised care for care home residents with patients, their families and the care home staff, ensuring the personalised care and support plans are recorded on the clinical system and the relevant template is completed. Gather appropriate information to record on ReSPECT forms. Discuss the hospital discharges for care home residents with patients, their relatives and the care home, as appropriate, ensuring the care plan is updated. Align the collection of new patient data/new patient checks with the requirements of the care home sector, using the new Care Home Patient Form, ensuring all information is entered onto the clinical system. Organise monthly care homes education meetings to discuss key topics including, but not limited to, ReSPECT Forms, Proxy Access, New Care Home Resident forms, Covid or flu vaccinations and consent. Coordinate annual structured Medication reviews with Care Home Matrons. Carry out any of the above coordinator duties in relation specifically to care home residents. Accountability The above list of duties is not exhaustive and may be subject to change, as deemed necessary. Person Specification Experience Essential Experience of working in health, social care and other support roles in direct contact with people, families or carers, in a paid or voluntary capacity. Experience of working within multi-professional team environments. Experience of supporting people, their families and carers in a related role. Experience of data collection and using tools to measure the impact of services. Desirable Experience of working directly in a care coordinator role, adult health and social care, learning support or public health/health improvement. Experience or training in personalised care and support planning. Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation. Personal Qualities and Attributes Essential Ability to actively listen, empathise with people and provide personalised support in a non-judgemental manner. Ability to provide a culturally sensitive service, supporting people from all backgrounds and communities, respecting lifestyles and diversity. Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential. Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders. Ability to identify risk and assess/manage risk when working with individuals. Able to recognise professional boundaries and understanding when it is appropriate or necessary to refer people back to other health professionals or agencies, eg, when there is a mental health need requiring a qualified practitioner. Ability to maintain effective working relationships and to promote collaborative practice with colleagues. Ability to demonstrate personal accountability, emotional resilience and to work well under pressure. Ability to plan, organise and prioritise work, using own initiative. Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. Must have completed a two-day PCI accredited care coordination training course or be willing to complete one prior to taking referrals. Qualifications Essential GCSE or Equivalent Grade A-C in English and Maths Skills and Knowledge Essential Understanding of personalised care and the comprehensive model of personalised care. Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers. Understanding of, and commitment to, equality, diversity and inclusion. Strong organisational skills, including planning, prioritising, time management and record keeping. Knowledge of how the NHS works, including primary care and PCNs. Ability to recognise and work within limits of own competence and to seek advice when needed. Understanding of the needs of older people/adults with disabilities or long-term conditions, particularly in relation to promoting their independence. Basic knowledge of long term conditions and the complexities involved. Desirable Knowledge of Safeguarding Children and Vulnerable Adults policies and processes. Person Specification Experience Essential Experience of working in health, social care and other support roles in direct contact with people, families or carers, in a paid or voluntary capacity. Experience of working within multi-professional team environments. Experience of supporting people, their families and carers in a related role. Experience of data collection and using tools to measure the impact of services. Desirable Experience of working directly in a care coordinator role, adult health and social care, learning support or public health/health improvement. Experience or training in personalised care and support planning. Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation. Personal Qualities and Attributes Essential Ability to actively listen, empathise with people and provide personalised support in a non-judgemental manner. Ability to provide a culturally sensitive service, supporting people from all backgrounds and communities, respecting lifestyles and diversity. Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential. Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders. Ability to identify risk and assess/manage risk when working with individuals. Able to recognise professional boundaries and understanding when it is appropriate or necessary to refer people back to other health professionals or agencies, eg, when there is a mental health need requiring a qualified practitioner. Ability to maintain effective working relationships and to promote collaborative practice with colleagues. Ability to demonstrate personal accountability, emotional resilience and to work well under pressure. Ability to plan, organise and prioritise work, using own initiative. Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. Must have completed a two-day PCI accredited care coordination training course or be willing to complete one prior to taking referrals. Qualifications Essential GCSE or Equivalent Grade A-C in English and Maths Skills and Knowledge Essential Understanding of personalised care and the comprehensive model of personalised care. Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers. Understanding of, and commitment to, equality, diversity and inclusion. Strong organisational skills, including planning, prioritising, time management and record keeping. Knowledge of how the NHS works, including primary care and PCNs. Ability to recognise and work within limits of own competence and to seek advice when needed. Understanding of the needs of older people/adults with disabilities or long-term conditions, particularly in relation to promoting their independence. Basic knowledge of long term conditions and the complexities involved. Desirable Knowledge of Safeguarding Children and Vulnerable Adults policies and processes. 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 Avisford Medical Group Address North End Road Yapton Arundel West Sussex BN18 0DU Employer's website https://www.avisford.co.uk (Opens in a new tab)