Job Details
Job summary
The Care Coordinators will work as part of a growing multi-disciplinary team within general practice, supporting patients from a number of practices in their Network. This role will give you will have the chance to shape the service and the role. You will be working with patients to help them understand their conditions and what matters to them, and match the support that is available locally to keep them happy and independent. This might involve working with clinicians looking after local Care Homes, organising PCN multi-disciplinary team meetings for clinical and non-clinical staff or working with a specific cohort of patients yourself perhaps frail elderly or a particular long term condition.
We are looking for a positive team player who strives to go the extra mile to help out colleagues and others who come into contact with the organisation. You really want to make a difference! We need someone who can build strong relationships with team members and is committed to meeting deadlines.
The role will require high standards and great attention to detail, in order to provide an excellent service to patients and colleagues.
Main duties of the job
As a Care Coordinator, you will:
Proactively identify and support individuals, including the frail, elderly, and those with long-term conditions.
Coordinate and navigate care and support across health and care services, with a focus on vulnerable housebound patients and enhanced health in care homes.
Collaborate with clinical and non-clinical teams to ensure people receive the support they need.
Empower patients to manage their conditions and access necessary services, enhancing their quality of life.
Work alongside social prescribing link workers for a comprehensive approach to personalized care.
Engage with diverse populations from various cultural and social backgrounds.
Care co-ordinators are highly motivated, forward-thinking, and experienced individuals who are:
Excellent communicators with strong interpersonal skills.
Organised, patient, and empathetic.
Experienced in health, social care, or support roles involving direct contact with people, families, or carers.
About us
2 sites in County Durham
We have a well -established partnership with 8 GP partners working alongside 6 salaried GPs, 4 Nurse Practitioners (who also do home visits) and full nursing and support team
We have in-house pharmacists which greatly reduces our admin work
We have PCN ARRS roles including social prescribers, mental health workers and physios
We teach medical students and F2 doctors and are a training practice
We have developed GPSI services in dermatology, minor surgery and ENT and run these services from our practice
Job descriptionJob responsibilities
a.Towork closely with practice and PCN healthcare roles, the CARE COORDINATOR is toidentify and work with a cohort of people to support their personalised carerequirements, including patients discharged from health or social care settingsto ensure any follow up actions are included and considered as part of thepatients personalised care plan, using any available decision support tools, templatesand software
b.Collatepatients identified and support needs into a single personalised care andsupport plan
c.Touse primary care software to coordinate recall lists for patients who are beingmonitored for chronic health conditions.This is a vital role in ensuring patients receive their annual review.
d.Towork with the PCN to proactively case find using population health intelligencedata
e.Tohelp people to manage their needs by answering their queries and supportingthem in making appointments and ensuring patients have good quality written orverbal information to help them make choices about their care.
f.Tomonitor all referrals, missed appointments, investigations, this will includecancer 2ww referrals and missed follow up appointments.
g.Torecord patient's demographic and simple health information as part of theirpersonalised care plan/record.
h.Workclosely with other social and health care professionals
i.Tosignpost patients to SPLW to access appropriate benefits where eligible as wellas taking up employment and training
j.Toassist patients to be better prepared to have conversations on shared decision makingand to improve awareness of shared decision making and related support tools
k.Toprovide patients with high quality, easy to understand information to assistthem in making choices about their care
l.Toliaise with other CARE COORDINATORs in other practices within the PCN and sharebest practice
m.Toassist patients to access self-management education courses, peer support orinterventions that support them in their health and well-being
n.Toprovide coordination and navigation of patients, and where appropriate theircarers, across health and social care services, where appropriate working handin hand with social prescribing link workers (SPLW) and cancer carecoordinators
o.Tosupport in the delivery of enhanced services and other service requirements onbehalf of the PCN
p.Toattend and participate in the delivery of multi-disciplinary teams (MDT) withinPCNs.
q.Toundertake all mandatory training and induction programmes
r.Tocontribute to and embrace the spectrum of clinical governance
s.Todevelop yourself and the role through participation in training and serviceredesign activities
t.Toattend a formal appraisal with their manager at least every 12 months. Once aperformance/training objective has been set, progress will be reviewed on aregular basis so that new objectives can be agreed.
u.Tocontribute to public health campaigns ( flu/covid clinics) through adviceor direct care
v.Tomaintain a clean, tidy, effective working area at all times
Person SpecificationExperience
Essential
Desirable
Qualifications
Essential
Desirable
