Care Coordinator - Haywards Heath Central PCN

Reports to: Operations Manager

Responsible to: PCN Clinical Director

Proposed salary: Band 4.1 – 4.7 on the ABC pay scale which is equivalent to £23,285.69 - £25,709.29 per annum dependent on experience, pro rata

Hours of work: Full time (37.5 hours) and part-time applications will be considered

Base: The successful candidate will be based predominantly at Dolphins Practice but there may be a need to cross cover to support both Core Network Practices as needed

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 Haywards Heath Central PCN

Haywards Heath Central Primary Care Network is a NHS Collaboration between two GP Practices – Dolphins Practice and Newtons 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 work at one base within a Primary Care Network.
• 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.
• 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.
• 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.