Care Coordinator - Horsham Central PCN

Reports to: Business and Transformation Manager

Responsible to: Clinical Director

Proposed salary: Band 4.1 – 5.4 on the ABC pay scale, which is equivalent to £23,285.69 - £28,385.13 per annum (dependent on experience)

Hours of work: Fulltime

Base: Holbrook Surgery and Riverside Medical Practice

About Alliance for Better Care CIC

Alliance for Better Care CIC is a GP Federation that unites 47 NHS GP practices across 12 Primary Care Networks in Sussex and Surrey. We support our Primary Care colleagues as well as their patients, to transform how healthcare is managed within the community.

As a membership organisation, our focus is to work in partnership with our members and help them to improve the provision of General Practices in the local area.

We work with – and listen to – our GP Practices, PCNs, Hospitals, Community Organisations and the Third Sector. These vital partnerships ensure that, together, we deliver a truly integrated approach that offers the support and expertise needed to effectively serve our communities. 

More about our organisation: www.allianceforbettercare.org

Our Values

•  We innovate

         If we can do something better, we should.

•  We are honest

        Even when it is difficult.

•  We care

        And put the patient first.

•  We are inclusive

        We listen and we act.

•  We deliver

        And we’re known to like a challenge!

 

About Horsham Central PCN

Horsham Central Primary Care Network is a NHS Collaboration between two GP Practices – Holbrook Surgery and Riverside Medical Practice - working together to provide enhanced access services.

Our surgery teams work closely, sharing expertise and resources to develop new services. Our vision is to continue to improve the quality of care that we provide in alignment with the needs of our patient population.

Our Primary Care Network builds on the existing primary care services and enables a greater provision of proactive, personalised and more integrated health and social care. We are supported by practitioners in additional roles who allow us to create bespoke multi-disciplinary teams based on the needs of our local population.  By working together with local community services, this allows us to make support available to people where it is most needed.

Study Leave/Training

There are opportunities for a study leave allowance.

Supervision

Regular supervisions on a one-to-one basis including an annual formal appraisal are held with a line manager. If you are in a patient-facing role, you will also receive regular Clinical Supervisions with a Clinical Supervisor. 

Benefits

• Generous annual leave allowance
• Access to NHS pension
• Bespoke training programme
• Cycle to Work Scheme
• Employee Assistance Programme
• Enhanced maternity pay
• NHS discounts
• Leadership Development Programme
• Salary sacrifice schemes – technology and electric vehicle
• Opportunities for secondments

Job summary

This role is to support the smooth co-ordination of patient care for one practice within the Primary Care Network for the benefit of our patients.

The Care Coordinator will be responsible for consulting with patients and determining their needs, developing care plans, coordinating patient-care services, educating them about their condition, empowering them to be independent whenever possible and working with the care team to evaluate interventions.

Primary duties and areas of responsibility

Key Responsibilities and Duties

• To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence.
• Use practice data to make informed decision, identify inequalities and initiate projects to improve services and the lives of our patients and community.
• To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patient’s home if needed.
• Liaise with Care Homes as necessary.

MDT Coordination

• Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting.
• Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions.

Managing a caseload

• Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence.
• Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions.
• Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacy team, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews.
• With the help of relevant clinical colleagues, develop a care plan to address patients’ personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare.
• Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans.
• Check in on the patient regularly and evaluate and document their progress.

Linking with other services

• Signpost team members, service users and carers to relevant services including the PCN Social Prescribing Link Worker Service.
• Liaise with the Social Prescriber and Mental Health Support Coordinator regarding patients that are identified as needing well-being support.
• Liaise with practice clinicians responsible for frailty regarding patients that are identified as needing ongoing support.
• Liaise with acute trusts, care homes, hospices, community and social care providers as required.

Record Keeping

• Keep accurate and up-to-date records of contact with patients, carers and professionals, including use of SystmOne to record patient contact on the medical record.
• Use accurate SNOMED codes to record patient contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomes.
• Manage reporting required and associated within the DES specifications for required services e.g IIF and other services such as EA.
• Report case studies and outcomes to the PCN on a quarterly basis.

General Responsibilities

• Work as part of the team to seek feedback, continually improve the service and contribute to business planning.
• Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
• Attend ongoing training and courses to keep abreast of new developments in health care.
• Treat patients with empathy and respect and conduct oneself in a professional manner.
• Attend and contribute to relevant meetings.
• Duties may vary from time to time, without changing the general character of the post or the level of responsibility.

Person Specification

Knowledge

Essential

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

Skills and Abilities

Essential

• Able to listen, empathise with people and provide person- centred support in a non-judgemental way.
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
• Committed to reducing health inequalities and proactively working to reach people from all communities.
• Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
• Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
• Able 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 link worker role e.g. when there is a mental health need requiring a qualified practitioner.
• Able to provide leadership and to finish work tasks.
• Able to maintain effective working relationships and to promote collaborative practice with all colleagues.
• Committed to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues
• Demonstrates personal accountability, emotional resilience and works well under pressure.
• Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
• High level of written and oral communication skills.

Desirable

• Excellent IT skills including Excel as well as knowledge of GP clinical systems, experience of data entry and coding.

Behaviours and values

Essential

• Able to work flexibly and enthusiastically within a team or on own initiative

Qualifications

Essential

• Demonstrable commitment to professional and personal development with a can do attitude

Desirable

• NVQ Level 3, Advanced level or equivalent qualifications or working towards
• Training in motivational coaching and interviewing or equivalent experience

Experience

Desirable

• Experience of working directly in either the NHS or Adult Social Care

 

Special Working Conditions

The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies.

The post-holder may have contact with body fluids i.e., wound exudates; urine etc. while in clinical practice and therefore should be immunised against common infectious diseases and Hepatitis B.

Health Clearance

Health clearance is required for this appointment. Applicants must complete an Occupational Health questionnaire and if required attend for a consultation prior to appointment.

Disclosure and Barring Service Checks

A Disclosure and Barring Service check and disclosure will be required before appointment for all posts with access to children or vulnerable adults or where the post holder has access to patient information.

Confidentiality and Disclosure of Information

In the course of your normal work you will come into possession of confidential information concerning patients, ABC and its staff. This information should always be treated according to the practice’s and ABC’s confidentiality policies. Any inappropriate disclosure may be subject to disciplinary procedures.

Raising concerns

Staff may on occasion have genuine concerns about healthcare matters and ABC endorses the principle that these must be raised in a responsible and appropriate manner, and in accordance with the Raising Concerns at Work Policy.

Data Quality/Security

The post holder is responsible for ensuring that he/she maintains the integrity and quality of both computerised and manual data.

Codes of conduct and professional standards

All staff must adhere to any codes of conduct or professional standards set by the regulatory bodies with whom they are registered or by professional bodies of which they are a member. It is the post holder’s responsibility to ensure they are familiar with these requirements and maintain their professional membership to the relevant body.

Risk (managerial and supervisory staff only)

Managers are responsible for implementing and monitoring any identified and appropriate risk management control measures within their designated area(s) and scope of responsibility. Full details are set out in ABC’s Risk Management Policy.

Health and Safety

All staff are advised that, under the Health and Safety at Work Act 1974 and associated legislation, it is the duty of every employee to take reasonable care for their own health and safety and that of other people who may be affected by their activities at work, and also to co-operate fully with ABC and others in connection with any arrangements to satisfy the statutory duties and responsibilities under the Act, including undertaking appropriate mandatory and health and safety training.

Infection Control

All staff must at all times be aware of their responsibilities for ensuring infection control and to maintain hygiene standards in accordance with infection control policies and instructions.

Personal Property

ABC is unable to accept responsibility for articles of personal property lost or damaged on its premises whether by burglary, fire, theft or otherwise and staff are advised to insure against all risks.

Equal Opportunities

Equality of opportunity is an integral part of ABC’s recruitment and selection process and recruiting managers must ensure that they comply fully with ABC’s Equality & Diversity Policy. ABC aims to ensure equality of opportunity for all irrespective of their age, colour, creed, ethnic or national origin, marital status, nationality, physical or mental disability, race, religious belief, sex or sexual orientation. 

No Smoking / Vaping

Smoking or Vaping by staff, patients and visitors, will not be permitted anywhere on ABC or practice premises.

Security

Staff must always wear their identity badge to assist in maintaining the security of the organisation; be observant, any suspicious behaviour must be reported to your line manage.

Safeguarding children and vulnerable adults

ABC as an employer is committed to safeguarding and promoting the welfare of children and adults at risk of harm and expects all employees to share this commitment. As this post is one that involves access to children and vulnerable adults during the course of their normal duties, an enhanced Disclosure and Barring Service (DBS) check will be required. All employees have a responsibility for safeguarding children and vulnerable adults in the course of their daily duties and for ensuring that they are aware of the specific duties relating to their role. Level 3 Adult and Child Safeguarding is a requirement for this role.

Job Description Agreement

This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to take into account development within the Practice. All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the Practice.

This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.