Job Description

Job Summary:

We are looking to recruit a compassionate and proactive Care Coordinator to join our innovative Integrated Neighbourhood Team (INT) based at Hedena Health GP surgery. The INT is a dynamic multidisciplinary team of GPs, nurses, Paramedics, care coordinators, and social prescribers who work together to improve access to healthcare for those with complex needs or barriers to accessing services. This person-centred service focuses on proactive, personalised support for patients and their families with the highest health and social care needs.

Established within Hedena Health in July 2024, the INT is an innovative and evolving service at the forefront of community-based healthcare. Working closely with colleagues at our INT partner practice Manor Surgery, across primary, secondary, community and social care, the INT project aims to provide intensive support to patients requiring help with a range of complex physical, psychological or social problems. This holistic model helps to improve health outcomes, enhance patient wellbeing and prevent hospital admission/re-admission. INT is central to Hedena Health's commitment to innovation and aligns with the NHS 10-Year Plan of improved, proactive community care.

In this varied and patient-facing role, you will coordinate clinics, manage patient care pathways, and ensure accurate input of clinical data. Direct contact with patients will be a key part of your work, supporting individuals to access the services they need and helping to remove barriers to care. You will work with a wide range of patients, including the frail and elderly, people with long-term conditions, and those not currently engaging with healthcare services.

You will work closely with GPs, Paramedics, nurses, social prescribers, clinical pharmacists, and other members of the Primary Care Network (PCN) to provide joined-up care and navigation support across health and social care services. A key aspect of the role will be supporting our weekly multidisciplinary meetings, which bring together health and care professionals from across Oxfordshire to plan and coordinate patient care.

We are looking for candidates who are compassionate, highly organised, and committed to providing excellent patient support. Strong communication, excellent interpersonal skills and high levels of IT literacy are essential. Experience with systems such as EMIS and Docman 10 would be desirable but not essential, as training can be provided.

This role offers a rewarding opportunity to work within an innovative and supportive team, making a real difference to the lives of patients in our community.

This role represents a unique opportunity to work at the forefront of integrated, community-based healthcare, supporting some of our most vulnerable patients and contributing to the ongoing development of a pioneering service.

Key Duties & Responsibilities:

Develop and implement proactive care services to help improve and maintain the health and wellbeing of our practice population. Proactively identify and work with a cohort of patients to support their personalised care requirements.

The duties and responsibilities may include any or all the items in the following list. Duties may be varied from time to time under the direction of the GP lead.

To put systems in place to identify patients who are elderly, frail or who have long term health needs and support To manage a virtual ward of the highest need patients, ensuring their progress and welfare is regularly checked and update patient records with details To co-ordinate care plans, making sure actions are completed by health care professionals To utilise population health intelligence to proactively identify other cohorts of patients, working with the clinical team to plan, implement and track interventions and report on the success of these To signpost to the relevant members of the practice team and outside organisations as appropriate To contact patients following hospital discharge to offer help or support and reduce the risk of loss of independence To ensure systems are in place to monitor those at risk of increased hospital admissions and A&E attendances To follow up on communications from out of hospital and in-patient services regarding changes in condition of patients to support the practice to respond proactively to potentially unmet needs To coordinate, attend and provide administrative support for MDT meetings. To disseminate information from these meetings to other practice staff as necessary To coordinate visits or arrange appointments at the practice for patients on the caseload To manage monthly recall searches and ensure patients are attending their Long-Term condition appointments. Following up on those not attending To maintain accurate and up to date records of patient contacts, entering notes onto EMIS Co-ordinate and liaise with patient services manager on promoting National and local Health campaigns. Use language line to communicate with patients who may otherwise not engage with our services. Completion of 2-day accredited training course as defined by Hedena.

Person Specification

Essential:

Highly literate and numerate with an excellent eye for detail Possess excellent communication skills both verbal and written, and demonstrate the ability to communicate complex information transparently and effectively Ability to communicate complex and sensitive information effectively with people at all levels by telephone, email, video conference and face to face Able to demonstrate a high level of IT skills (Microsoft word, excel, data) To be able to demonstrate being adaptive and comfortable with change Evidence of strong team working skills Excellent organisation and planning skills, able to meet changing priorities and time frames Able to cope with unexpected situations and provide solutions to problems Evidence of ability to complete tasks to a high standard with minimal supervision Flexible and adaptable and able to demonstrate the ability to make good decisions Required to work collaboratively and build good relationships with others, possessing excellent negotiation skills.

Desirable

:

Highly literate and numerate with an excellent eye for detail Full UK driving licence
Job Types: Full-time, Part-time, Fixed term contract
Contract length: 11 months

Benefits:

Company pension Free parking On-site parking
Schedule:

Monday to Friday
Work Location: In person

Reference ID: Care Coordinator (Administrator)