Job Description

Job summary

This is an exciting opportunity to join our evolving Integrated Neighbourhood Team across 3 Harbours and Bosvena Primary Care Network. You will be working alongside our care coordinators, clinicians, community nursing teams as well as volunteer and community sector providers.

The role of Care Co-ordinator is vital role within our Primary Care Network Integrated Neighbourhood Team (INT) proactively identifying cases, co-ordinating and navigating care and support across health, care and support services to provide a personalised care approach. The Care Coordinator will act as a central point of contact to ensure appropriate support is made available to people and their carers; enabling them to understand and manage their conditions while ensuring their changing needs are addressed.

Bosvena and 3H are seeking care co-ordination role primarily to support our emerging frailty and health inequalities teams

Main duties of the job

The Care Coordinator will act as a central point of contact to ensure appropriate support is made available to people and their carers; enabling them to understand and manage their conditions while ensuring their changing needs are addressed.

Case Identification

:

Support the team as required to undertake digital risk stratification Co-ordinate information for MDT platforms

Personalised Care and Support Planning (PCSP):

Co-ordinate PCSP digitally Co-ordinate informational continuity including multi-agency meetings and communications Undertake clinical coding to create reliable patient records used for diagnosing accurately, planning treatment, and ensuring patient safety. Competently use clinical systems and templates to capture, and report patient records. Follow-up on communications from out of hospital and in-patient services. Work with commissioners, Integrated Neighbourhood Team members and other agencies to support and further develop the Care Coordinator role.

Coordinated and Multi-Professional Working:

Be responsible for coordinating the care of each patient, ensuring close multi-agency and multi-professional working within the local Integrated Neighbourhood Team.

About us

Our primary care network spans coastal, town and rural Cornwall including Bodmin, Fowey, Lostwithiel and Par. We are developing our Integrated Neighbourhood Team, working with social care, community partners, secondary care and voluntary sector providers, to deliver high quality, patient centred health care across our geography.

Job responsibilities

General

Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice. Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing. Provide co-ordination and navigation across services, helping to ensure people and their carers receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other General Practice team members within the INT to proactively identify and manage a caseload, and where appropriate, refer back to other health practitioners within the PCN. Support the co-ordination and delivery of multidisciplinary teams with the PCN, if required. Identify people, using tools such as the Personalised Proactive Whiteboard, who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations.

Other responsibilities

Applying PCN policies, standards and guidance. Contributing to the teaching and training of trainees, new employees and employees who are undertaking training, as appropriate. Awareness of and compliance with all relevant policies/guidelines for your role, e.g. prescribing, confidentiality, data protection, health and safety. Contributing to evaluation/audit and clinical standard setting within the organisation as applicable to your role. Attending training, meetings and other meetings and events organised by the Practices, PCN/INT, or other agencies such as the ICB, where appropriate. Contributing to audits and written returns to ensure that the PCN/INT meets quality standards and receives the designated funding, as appropriate to your role. Treating colleagues with courtesy and respect. Complying with the PCN/INT values, and the values of your team.

Confidentiality

Comply with the Confidentiality Agreement.

Working conditions

This role requires consideration of the following

Frequent, prolonged VDU use Time-pressured environment High levels of accuracy and attention to detail essential at all times Exposure to distressing situations and written material

Experience

Essential

Working with healthcare professionals and/or previous experience in the NHS or social care. Coordinating with multiple stakeholders or individuals to meet specified outcomes Experience providing advice/signposting Using a patient clinical system Awareness of how and when to signpost Knowledge of safeguarding interventions Awareness of the Mental Capacity Act Skilled in the use of person-centred measurement and outcomes delivery

Desirable

Awareness of relevant Health and Social Care legislation and a developed knowledge of crisis intervention Experience of undertaking quality improvement activity Sound understanding of disease prevention and the NHS choices website Knowledge of a range of local community groups which support wellbeing

PRACTICAL, INTELLECTUAL, ANALYTICAL AND ORGANISATIONAL SKILLS

Essential

Excellent verbal communication skills with the ability to communicate effectively at all levels including with patients, carers, specialist services, GPs and colleagues. Good technical proficiency (for example: office applications) and experience using a clinical system such as EMIS Web Able to work independently and manage own workload Able to build strong professional relationships Demonstrate experience of effective planning and organisation skills to deliver targets to deadlines Proven record of excellent written communication skills and a high level of health literacy Understanding of social determinants of health and how these can be addressed with patients Able to analyse and interpret information and present results in a clear and concise manner Creative, flexible and sensitive approach to working with people with diverse support needs Ability to reflect on and share best practice with peers Able to travel within the Bosvena and Three Harbours geography as required : own car and driving licence essential Passionate about combatting disadvantage and inequality in healthcare Able to work well as part of a team

Qualifications

Essential

Educated to GCSE level or equivalent

Desirable

Relevant NVQ Level 3 qualification or equivalent
Job Type: Full-time

Pay: 24,937.00-26,598.00 per year

Work Location: In person