Job summary
North KerrierEast Primary Care Network (PCN)
Part-time Care Coordinator - upto 25 hours per week - Fixed Term for 6 months
Would you like to be part ofan inclusive, supportive, and innovative team, that is co-located and where itis essential to enjoy daily coffee with your colleagues? good beans provided! If you thinkyou would be interested in joining our Health and wellbeing team then readon.
The CareCoordinator is an integral part of the PCN Health and Well-being team and is akey contact to support people navigate and signpost to other key services.
Main duties of the job
The CareCoordinator will be involved in supporting clinical teams to proactivelyidentify and work with people, including the frail/elderly and those withlong-term conditions, eg diabetes, cancer, mental health and COPD, to provideproactive, person-centred care planning, helping coordinate care, by bringingtogether the different specialists whose help that individual might need. Thismight involve a wide range of services, such as hospital care, community care,social care, housing and the voluntary sector.
Therole will support the delivery of better outcomes for people living withmultiple long-term conditions, to help them improve the quality of their life,fostering self-care, independence and choice.
About us
Based in the West Integrated Care Area, North Kerrier East Primary Care Network, are a forward thinking group of GPpractices (Leatside Health Centre and Veor Surgery) supporting a local population ofjust over 30,000, providing clinical services and health and wellbeing support to people living in thetowns of Redruth and Camborne, as well as surrounding villages. We have astrong focus on health promotion and personalised care, supporting people tomake informed decisions about their health and social care.
Job description
Job responsibilities
1. Work as part of the PCN health and wellbeing team, coordinating carebetween GPs, practice nurses, clinical pharmacists, physiotherapists, mentalhealth practitioners, and health and well-being coaches;
2. Record all patient contacts and work on the clinical system against the patientrecord;
3. Work withindividual patients, their families and carers, using a holistic approach, to identifytheir goals for care, and agree a personalised care and support plan for theircare or support with signposting to other services;
4. Supportdelivery of care plans by co-coordinating input from arange of different professionals and services, and helping patients and theircarers/family to navigate across health and social care services;
5. Helppatients to manage their needs through answering queries, being a first pointof contact across the PCN, and by making and managing appointments;
6. Support patients to utilise decision aids inpreparation for a shared decision-making conversationand ensure that they, and their carers/family, have access to good qualitywritten and verbal information to help them make choices about their care;
7. Make use of tools such as patient health questionnaires when engagingwith patients;
8. Help patients to access self-management education courses, peer supportor other interventions that support them in improving their health and wellbeing.
9. Undertake regular reviews of the personalised care and support plansdeveloped with patients;
10. Work inline with national best practice when developing personalised care and supportplans;
11. Work with patients over the phone, in person inthe practice or for those who are housebound where necessary carry out homevisits.
12. As directed, use practice level reports to identify suitable cohortsof patients to deliver personalised care, supporting with specialist clinics;
13. Provide accurate and timely data to support audit andmonitoring of the service, and any data returns as required by the West IntegratedCare Area;
14. Keep accurate and up to date records of contacts with patients andtheir carers families in clinical systems and in their care plan;
15. Follow up documentation required for care planning from otherorganisations, making use of Local Care Record where useful;
16. Ensurethat a proper handover of care between different settings has taken place, includingmutual transfer of all organisations communications and patient notes andensuring care packages are set up;
17. Manageany necessary meetings to support care planning, identifying patients fordiscussion, organising the meeting and circulating required informationbeforehand as necessary
18. Ensurethat meeting actions are recorded, disseminated and followed up in a timelyway; so relevant practitioners are aware of meeting decisions and actions /outcomes, and chase for action resolution and update;
19. Networkand develop strong relationships with key organisations involved in the patientscare planning;
20. General administration duties to support the PrimaryCare Network Business Manager and team.
21. Please note this is not a clinical role.
Person Specification
Qualifications
Essential
22. Good level of education.
23. Proficient in the use of technology, supported with relevant qualifications and proven experience.
Desirable
24. Higher level qualification such as NVQ in health and social care Level 3.
25. Qualification relevant to health or social care or children.
26. IT qualifications.
Experience
Essential
27. Experience of working in health, social care, third sector or information and support services with direct contact with people, families, and professionals.
28. Customer care experience.
29. Significant proven experience in organisation, planning and coordinating skills.
30. Ability to prioritise own workload, use initiative and meet deadlines.
31. Able to analyse and interpret data.
32. Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience.
33. Proven experience in using computers with an ability to use Microsoft office packages and IT systems.
34. Driving license and access to transport.
Desirable
35. Experience of working in health services.
36. Experience of working as a care coordinator or social prescriber.
37. Experience or training in personalised care and support planning.
38. Experience of working with elderly, children or vulnerable people, complying with best practice and relevant legislation.