Job Description

Care Co-ordinator, Team Up! Derbyshire Dales Primary Care Network Ltd.

Salary:

27,485 - 30,162 per annum, pro rata (dependent upon skills and experience)

Reports to

: PCN

/

Team Up Management Team

Working Pattern:

Monday to Friday 10am to 6pm with 30 min break

Job Type:

Permanent subject to 6 month probation

Location:

Scholes Mill, Old Coach Road, Tansley, DE4 5FY

The post holder may be required to work across the Derbyshire Dales Primary Care Network (PCN) area.

Leave Entitlement:

27 days per annum plus bank holidays (pro rata)

Job summary

Join us at the start of an exciting, new, and challenging healthcare initiative working with Derbyshire Dales PCN Home Visiting Service (HVS), also known as Team Up. Derbyshire Dales PCN is seeking a dedicated and self-motivated Care Co-ordinator to work alongside and support a multi-disciplinary team, to provide care to our housebound and patients residing in care or residential homes.

This is an exciting opportunity to be at the forefront of the delivery of our new Team Up/Ageing Well model of care. The role will operate across the traditional health and social care organisational boundaries, including with our GP practice partners, Community Rapid Response services and Falls services, ambulance and out of hours services to help clinically deliver the service on a day-to-day basis. The aim for the service is to ultimately provide a holistic approach to acute on day/rapid response services, enhanced health in care homes and enhanced proactive care for older people with frailty and patients with multi-faceted health problems.

Main duties of the job

The Care Co-ordinator will be part of the Acute Home Visiting Team (AHVT), who are responsible for managing planned long-term care. The Care Co-ordinators are a pivotal role to the AHVT and will be the interface between service users, families, carers, primary, community and secondary care, social care, mental health, out of hours services and voluntary organisations. You will also contribute to tackling health inequalities in health and social care particularly regarding individuals with long-term conditions and maintain IT based information systems and take responsibility to produce performance data, analyse and report for the service. You will be responsible for co-ordinating, integrating and delivering support to patients, and ensure effective and synchronised care is available to patients, proactively identifying their personalised care needs.

About us

Derbyshire Dales Primary Care Network is a group of 7 forward thinking and progressive practices (population circa 50k) who have developed friendly and effective working relationships with each other. The Derbyshire Dales are a great place to live and work. We have a mix of country towns and rural hamlets spread across a large geographic area. Your employer would be Derbyshire Dales Primary Care Network Ltd, and you would be entitled to be part of the NHS pension scheme.

Key Duties Tasks and Responsibilities

Case Work Discussion

Overall responsibility for the regular multi-disciplinary team meetings and the smooth running of integrated care within the team setting. The key role of the Care Co-ordinator will be to schedule regular AHVT meetings, manage the meeting agenda items and identifying key themes for discussion, circulating information to the team in advance of the meeting. Collate, analyse, and present data and information to the team. Co-ordinate and manage the administrative functions of the AHVT meetings. Note any key changes and team agreements and actions required and disseminate these to the team. Manage the team's database to track case management, service user journeys and outcomes, and undertake analysis of caseload information for audit, service evaluation, and performance management purposes, to be reported back to the MDT and Team Up Clinical and Operational Leads.

Patient Identification

Receive and collate information from hospital admissions and discharges, plus out of hours calls, ambulance conveyances, and social care, and present this to the AHVT. Identify people with complex needs and new service users and present this information to the AHVT. Signpost team members, service users, families, and carers to relevant services, referring as appropriate. Contribute to assessment to identify a specific need, to maintain independence in the place they call home (own home, residential or care home). Attend visits as appropriate to act as chaperone or to facilitate non-clinical referrals.

Maintenance of IT based information systems and responsibility for key performance data

To ensure the IT requirements for recording activity are adhered to in collaboration with other team members. To analyse and provide agreed performance/activity data on behalf of the AHVT for monthly reporting to the Integrated Care Board, and to support ongoing evaluation and success of the service.

Communication and Relationships

Work closely with health and social care system partners to ensure referrals into the service are received and managed, and to co-ordinate personalised care for the patients on the caseload. Develop excellent working relationships with internal and external stakeholders and communicate effectively with service users, families, carers, residential and care homes, AHVT members and other organisational representatives to ensure there is smooth access into the service, and to ensure patients receive the input they need from other services as required. Fulfil an intermediary role between administrative staff, clinicians, social workers, allied health professionals, community teams and mental health teams. Maintain relevant systems for colleagues involved in care, to be able to access. Communicate to the team and relevant organisations of any 'good news' case management stories. Refer complex cases to the AHVT via multi-disciplinary team meetings. Build networks within the scope of the role to raise awareness and identify groups and services available within the community. Raise any potential safeguarding concerns with the relevant clinicians within the team Liaise with AHVT members to ensure any outstanding actions required by team to follow-up/facilitate tests or treatment/onward refer patients to other services. Produce accurate, contemporaneous, and complete records of patient contact, consistent with legislation, policies, and procedures. Understand own role and scope, work within this scope of practice and identify how this may develop over time.

Supporting Care Delivery

Be a key point of contact for service users, families, carers, residential and care homes, ensure there is a key point of contact within the team for all service users from a clinical perspective, and act as an advocate for patients, families, and carers to support the assessment and identification of specific needs to maintain independence in the community. Prepare proactive care plans for appropriate patients. Work with the clinical team to provide proactive care for health promotion and/or long-term condition monitoring and management. Follow through actions identified by the AHVT including arranging tests, referrals, signposting etc. Follow through with service users and others involved to ensure all services/care arrangements are in place. Provide 'welcome home' calls after acute or community hospital stays - for individuals who are 'frequent flyers', have complex needs or are at risk of readmission. Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence. Discuss, highlight, and work with the team to create opportunities to improve patient care.

Other Responsibilities

Manage and prioritise workload daily and deal with the competing demands of the team. Plan and respond to workload according to operational priorities. Participate in the induction of new staff to the team as required. Take part in regular performance appraisal. Take responsibility for self-development on a continuous basis and undertake any training required to maintain competency including mandatory training. Participate in audits/service evaluation and learning events necessary to the team. Use own initiative to follow up activities, facilitate smooth service delivery for service users and to act as facilitator to ensure actions required by the team are undertaken as appropriate. At times, lead or contribute to the planning and delivery of improvement projects. Participate in the maintenance of quality governance systems and processes across the organisation and its activities. Disseminate learning and information gained to other team members to share good practice. Assess own learning needs and undertake learning as appropriate.
The list of duties above is not exhaustive and is intended to outline the main activities of the post holder.

Person Specification

Criteria

Essential

Desirable

Experience

Experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field (including unpaid work)

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

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

Experience of working with or in general practice.

Working in a multi-disciplinary setting where influence and negotiation is required.

Knowledge/familiarity with medical terminology.

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

Experience in use of databases.

Vulnerable adults awareness.

Experience of care of the elderly or frail

Skills and Knowledge

Knowledge of the personalised care approach.

Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails, and the internet to create simple plans and reports.

Creative problem solver and willing to search for hard-to-find information.

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

Access to own transport and ability to travel across the locality on a regular basis.

Continued commitment to improve skills and ability in new areas of work.

Knowledge of general practice clinical systems, such as, EMIS and SystmOne. Ability to read large amounts of information and extract the salient points.

Data analysis and reporting.

Qualifications

ECDL or equivalent Diploma/HNC level (or relevant experience)

NVQ Level 2 Business Administration (or relevant experience)

Demonstrable commitment to professional and personal continuous development.

Training in motivational coaching and interviewing or equivalent.

Knowledge of primary care IT Systems Qualified to NVQ level 2 in Health and Social Care.

As this is a new evolving service, the role may need to be reviewed and developed in line with changing priorities and developing service.

Stakeholder Management

Develop effective working relationships with professionals both internal and external to the service.

Act as an integrator ensuring care is co-ordinated across the interface with Primary Care and other health and social care partners, to ensure an effective, efficient, and high-quality service for service users.

Key Relationships

The post holder will demonstrate professional, well established, and effective communication skills, both within and external to the organisation.

Service Clinical Lead

Acute Home Visiting Team members

PCN Senior Leadership Team

PCN Core team

PCN and System Clinical and Professional Leads

Professionals across the Services, including Mental Health

Community Nursing, Therapy and Specialist Community Teams and their Managers

Social Care teams and their managers

Patients, service users, carers, and their families

General Practice

Other Primary Care Networks

Acute hospitals

Voluntary sector organisations

Other local Partner organisations and personnel

Local service commissioners and other partners in Joined Up Care Derbyshire system

Confidentiality

While seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

In the performance of the duties outlined in this , the post-holder may have access to confidential information relating to patients and their carers, PCN staff and other healthcare workers. All such information from any source is to be regarded as strictly confidential.

Health and Safety

The post-holder will assist in promoting and maintaining their own and others' health, safety and security as defined in the organisation's Health & Safety Policy, to include:

Using personal security systems within the workplace according to guidelines. Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks. Making effective use of training to update knowledge and skills. Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards. Reporting potential risks identified.

Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers, and colleagues, to include:

Acting in a way that recognises the importance of people's rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation. Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.

Quality

The post-holder will strive to maintain quality within the work, and will:

Alert other team members to issues of Clinical Governance, quality, and risk, participate in Significant Event Analysis reviews. Assess own performance and take accountability for own actions, either directly or under supervision. Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team's performance. Work effectively with individuals in other agencies to meet patients' needs. Effectively manage their own time, workload, and resources. He/she will also contribute to the overall teamworking, putting the needs of the organisation first.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Appendix

Ageing Well and Team Up! Derbyshire

The National Ageing Well programme aims to build upon the progress already made with partners on service provision at the interface between health and social care, with a focus on the prevention of avoidable hospital and residential care admissions and pro-active care provision linked into primary care network services.

"Team Up! Derbyshire" is the local approach. The plan is to create one team across Health and Social Care who see all housebound patients in a neighbourhood. It means one team to do it all: urgent, planned, or anticipatory care and support.

This is not a new or 'add on' to existing services but a "teaming up" of existing services which incorporates all the requirements of the national "Ageing Well Programme."

Our local ambition is even greater than the national programme - we're aiming not only to transform anticipatory care, community urgent response and support to care homes, but also GP acute home visiting.

There are three key transformation programmes that constitute the Ageing Well and Team Up! Derbyshire programme:

Community Urgent Response and Home Visiting

- building on existing intermediate care service provision with a goal of implementing 2-hour/2-day targets for community crisis response and reablement. This includes responding to and meeting the needs of people at the end of their life and with dementia.

Anticipatory Care/Community Teams

- implement 'anticipatory care' for complex patients at risk of unwarranted health outcomes. Target support towards older people with moderate frailty as well as people of all ages living with multiple comorbidities. Develop a proactive population health approach for people with frailty through Primary Care Networks, providing preventative care and supporting early identification and avoidable admissions.

Enhanced Health in Care Homes

(EHCH) model - to scale up the successful vanguard EHCH approach to improve the provision and quality of NHS healthcare across all care homes in England. The intention is to help reduce avoidable emergency admissions, ambulance conveyances and sub-optimal medication regimes.

The service development and delivery of this work cannot be done in isolation because of the interdependencies and the system collaboration required to realise the programme ambition.

Job Types: Full-time, Permanent

Pay: 27,485.00-30,162.00 per year

Benefits:

Company pension
Work Location: In person