Job Description

PCN Care Co-ordinators play an important role providing extra time, capacity and expertise to support patients to be actively involved in managing their care and supported to make the choices that are right for them. Working closely with GPs, GP practice teams and other health and care professionals involved in care, they act as a central point of contact for patients.

This role is an integral part of the PCN's personalised care team, working alongside social prescribing link workers and health and wellbeing coaches to promote and embed a personalised care approach.

Care Co-ordinators work independently as well as part of a team, are forward thinking, caring, dedicated, reliable and person-focused individuals who enjoys working with a wide range of people.

Our PCN

Cambridge City PCN is a collaboration of six GP surgeries across South Cambridgeshire; supporting a patient population of +50,000.

Nuffield Road Medical Centre Arbury Road Surgery York Street Medical Centre Bottisham Medical Practice Cambridge Access Surgery East Barnwell Health Centre
Interviews will be held in December.

Primary Responsibilities

Work with people, their families and carers to improve their understanding of the patients' condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes Help people to manage their needs through answering queries, making and managing appointments, and ensuring 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 that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health Support people to take up training and employment, and to access appropriate benefits where eligible; for example, through referral to social prescribing link workers Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN Support the coordination and delivery of multidisciplinary teams with the PCN Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations Explore and assist people to access a personal health budget where appropriate Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies Identify unpaid carers and help them access services to support them Conduct follow-ups on communications from out of hospital and in-patient services Maintain records of referrals and interventions to enable monitoring and evaluation of the service Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the person's circumstances Contribute to risk and impact assessments, monitoring and evaluations of the service Work with commissioners, integrated locality teams and other agencies to support and further develop the role

Key Tasks

Enable access to personalised care and support including taking responsibility within the practice for all queries and referrals to the personalised care team related to care needs/responsibilities. Take referrals for individuals or proactively identify people who could benefit from support through care coordination Assist patients on your caseload with simple form completion, e.g. Blue badge forms Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs Work towards increasing patients' understanding of how to manage and develop health and wellbeing through offering advice and guidance Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them Support people who DNA secondary care referrals but still have an unmet need to understand and address barriers to attendance.

Use tools to measure people's levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly

Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register Support people to develop and implement personalised care and support plans Review and update personalised care and support plans at regular intervals Support other members of the personalised care team in gathering information from external organisations Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes Where a personal health budget is an option, to work with the person and the local ICS team to provide advice and support as appropriate Support the integrated neighbourhood team in identifying patients suitable for the HIU project and supporting their care as part of the project

Coordinate and integrate care

Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisation Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system Refer onwards to social prescribing link workers and health and wellbeing coaches where required Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the person's care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported Actively participate in multidisciplinary team meetings in the PCN as and when appropriate Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns Record what interventions are used to support people, and how people are developing on their health and care journey Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service

Professional development

Work with a named clinical point of contact for advice and support Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.

Key Working Relationships

The post holder will be required to maintain constructive relationships with a broad range of internal and external stakeholders within and beyond the organisation. Key relationships will include:

GPs and GP practice staff Patients and their carers Community Specialist Practitioners Community Nursing Staff Care and Residential Home Staff Secondary Care discharge teams Integrated Neighbourhood teams & affiliates

Personal Specification

Essential

Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way

Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity

Commitment to reducing health inequalities and proactively working to reach people from diverse communities

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, community groups, partner agencies and stakeholders

Ability to identify risk and assess / manage risk when working with individuals

Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role - e.g. when there is a mental health need requiring a qualified practitioner

Ability to work from an asset-based approach, building on existing community and personal assets

Ability to maintain effective working relationships and to promote collaborative practice with all colleagues

Ability to demonstrate personal accountability, emotional resilience and work well under pressure

Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines

Knowledge of, and ability to work to policies and procedures, including ? confidentiality, safeguarding, lone working, information governance, and health and safety

NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards

Demonstrable commitment to professional and personal development is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute

Experience of partnership/collaborative working and of building relationships across a variety of organisations

Proficient in MS Office and web -based services

Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions

Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own home

Desirable

Experience of using clinical systems such as System1

Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement (including unpaid work)

Experience of supporting people, their families and carers in a related role (including unpaid work)

Experience of supporting people with their mental health, either in a paid, unpaid or informal capacity

Experience of working with the VCSE sector (in a paid or unpaid capacity), including with volunteers and small community groups

Experience of data collection and providing monitoring information to assess the impact of services

Knowledge of the personalised care approach

Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities

Knowledge of community development approaches

Knowledge of motivational coaching and interview skills

Knowledge of VCSE and community services in the locality

This post is subject to enhanced DBS checks.

Job Types: Full-time, Part-time, Permanent, Fixed term contract

Pay: From 13.00 per hour

Expected hours: 30 - 37.5 per week

Benefits:

Company pension
Experience:

Primary care: 1 year (preferred)
Licence/Certification:

Drivers license (required)
Work authorisation:

United Kingdom (required)
Work Location: In person