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4PCN (Primary Care Network)

Hanham Health, Kingswood Health Centre, Cadbury Heath Health Centre and Close Farm

Care Coordinator - Job Description

Reporting to: PCN Operations Manager/PCN Manager

Hours: 37.5 hours per week

Salary: £12.18 per hour rising to £12.86 per hour once training and probation period is completed satisfactorily

Base: Based at Kingswood Health Centre, but travel within the PCN area is required

Job Overview

Care co-ordinators provide extra time, capacity, and expertise to enable patients with enhanced needs to access the services and support they require to improve their health and wellbeing, helping to improve their quality of life and reducing health care inequalities.

They ensure these patients, and their carers have access to good quality information to help them make informed choices about their care.

They proactively identify and liaise with an identified cohort of patients to support their personalised care requirements, making sure that the appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.

The Care co-ordinators work with groups of patients identified by local priorities, health inequalities or using population health management risk stratification. At present the current focus is on patients with learning disabilities (LD), adults with severe mental illness (SMI) and adults looking to engage with weight loss services, but other groups will also form part of the post holders work plan.

Job Description

You will proactively organise and complete health check appointments for patients where appropriate, either in their own homes or at their practice, providing them with tools to best prepare them for shared decision making conversations. This may include gathering information directly or providing information to the patient and/or carer.

You will help patients and their carers by being a point of contact/advocate. With your support, it is hoped patients will navigate or signpost effectively for their health needs and ensure they have excellent good quality written and verbal information. This may take the form of being the link between the practice, the multi-disciplinary team, or the wider healthcare community, or signposting towards services such as social prescribing, OneYou South Gloucestershire etc.

Supporting People with Learning Disabilities

• You will liaise with practice teams to ensure that there is a proactive call and recall system for patients 14 years of age and over with learning disabilities, booking and completing their annual health check, including taking any blood tests, blood pressure checks, height and weight measurements as required. Also providing information to help them get the most from their review.
• You will proactively engage with these patients, carers and the practices to ensure maximum uptake of these reviews and follow up any patients who fail to attend their appointments.
• You will ensure that contacts with the patient are recorded appropriately and that checks are coded and recorded accurately.
• You will act as a link between Support Workers, the GP and any PCN, primary, community or secondary care colleagues, supporting any onward referrals, care planning or administrative patient needs as appropriate.

Serious Mental Illness Reviews

• You will liaise with practice teams to ensure there is proactive call and recall system for patients with Severe Mental Illness, booking and completing their mental health review, including taking any blood tests, blood pressure checks, height and weight measurements as required.
• You will proactively engage with these patients, carers and the practices to ensure maximum uptake of these reviews and follow up any patients who fail to attend their appointments.
• You will ensure that contacts with the patient are recorded appropriately and that checks are coded and recorded accurately.
• You will act as a link between Support Workers, the GP and any PCN, primary, community or secondary care colleagues, supporting any onward referrals, care planning or administrative patient needs as appropriate.

Weight Management Services

• You will be the PCN administrative lead for these services, identifying suitable patients and making contact in the first instance.
• You will be involved in discussions with patients to determine how motivated they are to engage with services.
• You will book appointments and make referrals as appropriate and may be required to gather baseline information (such as height, weight etc) as per the protocols for these services.
• You will ensure that contacts with patient are recorded appropriately and that checks are coded and recorded accurately.

General Duties

• You will ensure safeguarding issues or patient related concerns are raised appropriately to a suitable individual.
• You will help administratively with any auditing or searching of GP clinical systems.

This job description is only a brief summary of what a Care Co-ordinators job will entail, and the role will expand and change over time as the needs of the PCN changes, the requirement of the Network DES expands, and the priorities of the population evolve. Any changes will be discussed with the postholder in advance and the job description will be reviewed annually during appraisal.

This list of duties is not intended to be exhaustive but indicates the main areas of work and may be subject to change to meet the changing needs of the service.

Supervision Received

The postholder will be operationally line managed by the PCN Operations Manager, with feedback and support received from the PCN Manager, Clinical Director, and other members of the PCN board.

Supervision Exercised

The postholder will not have any operational line management responsibility.

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 Enhanced Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Person Specification

Essential

• GCSE Maths and English
• A commitment to continuing personal and professional development
• Experience of working within healthcare or the voluntary/community sector, supporting vulnerable groups complying with best practice
• Experience of working within multi-professional team environments
• Experience of supporting people, their families, or their carers in a related role
• Strong organisations skills including planning, prioritising, time management and record keeping
• Good IT skills, including the ability to use Microsoft Office applications, Word, Excel, PowerPoint, Outlook as well as learn new software packages
• Ability to actively listen, empathise and provide personalised support in a non-judgemental way, to inspire trust and confidence and motivate people to reach their potential
• Ability to provide a culturally sensitive service, supporting people from all backgrounds and communities, respecting lifestyle and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• High level of written and verbal communication skills and the ability to communicate effectively both verbally and in writing, with people, their families, carers and other stakeholders
• Ability to identify risk and assess and manage when working with individuals
• Have a strong awareness and understanding of when it is appropriate to refer back to other health professionals/agencies
• Ability to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients including GPs, Practice Nurses, healthcare professionals and other practice staff
• Ability to maintain effective working relationships with all colleagues and to work flexibly and enthusiastically within a team or working under own initiative
• Ability to organise, plan and prioritise under own initiative and when under pressure and meeting deadlines
• Ability to work across the PCN sites as required

Desirable

• Care Certificate NVQ in Health and Social Care
• Knowledge of and ability to work to policies and procedures including confidentiality, safeguarding, information governance and health and safety
• Experience of using EMIS Web
• Ability to provide motivational coaching to support people’s behaviour change
• Understanding of the wider determinants of health, including social economic and environmental factors and their impact on communities, individuals, their families, and carers
• Basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social
• Ability to recognise and work within limits of competence and seek advice when needed
• Familiar with local resources and services and how to access them
• Knowledge of how the NHS works including PCNs
• Knowledge of safeguarding policies and processes
• Demonstrable commitment to professional and personal development
• Experience or training in personalised care and support planning

Job Type: Full-time

Salary: £12.18 per hour

Benefits:

• Company pension

Schedule:

• Monday to Friday

Work Location: In person

Application deadline: 06/08/2023