care manager Taunton, England
Job description
The Care Coordinator for Inequalities and Access will work with the PCN member practices supporting them to identify and address barriers to help improve patient access to the full range of general practice services. Some groups of patients do not currently experience easy access to general practice services and subsequently do not experience the same health outcomes as the rest of the population. This is a pivotal role and is required to champion the needs of those most vulnerable to poor health outcomes who often struggle to access healthcare. Our Care Coordinator will use assertive outreach skills to engage people who are hard to reach.
You will reach out to those communities who sometimes feel voiceless to give them the help and support they need. You will support patients in preparing for or in following up clinical conversations they have with PCN primary care professionals. You will be working with patients to help ensure they have the right support and to signpost to the relevant local voluntary sector organisations that can support them with their non-clinical health needs. Support provided directly with patients and their carers would include supporting the development of personalised plans, utilising decision aids, providing information, making appointments, coordination and navigation for people and their carers across health and care services.
Key Responsibilities Work with the PCN member practices to identify and address access barriers for those who struggle to access healthcare. Working with other PCN Care Coordinators, raise awareness of health promotion, screening, NHS Health Checks and LD Health checks with patients. Liaise with GPs and practice teams to identify individual patients who struggle to access health services and/or coordinate effectively with all relevant services. Act as a point of contact between GP, patients, carers and other agencies.
Manage patient-initiated calls for help/signposting etc., ensuring patients are directed to appropriate services. Support patients to self-manage their care including referrals to Social Prescribing Link Workers where a patient may benefit from this service. Link in with and build relationships with the wider PCN team, Social Prescribers, Pharmacists, Health and Wellbeing Coaches and other clinical/non-clinical partners involved in the patients care. Holistically bring together all of a persons identified care and support needs, and explore options to help them achieve their needs.
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. 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 professionals. Primary Duties and Areas of Responsibility Direct patient facing work Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. Support patients to utilise decision aids in preparation for a shared decision-making conversation.
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. Support people to take up training and employment, and to access appropriate benefits where eligible. Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.
Explore and assist people to access personal health budgets where appropriate. Communication and collaborative working relationships Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs. Liaise with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including care coordinators. Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT.
Keep the PCN aware of good news stories. Communicate effectively with service users and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Manage and prioritise workload on a daily basis, dealing with competing demands. Other responsibilities To act at all times in an anti-discriminatory manner.
To be able to plan and respond to workload according to operational priorities. To support the delivery of these functions across wider locality areas where necessary. To undertake any training required in order to maintain competency including mandatory training. To contribute to, and work within a safe working environment.
To carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures. To take responsibility for self-development on a continuous basis, undertaking on-the-job training as required. To be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment. Patient Care Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding.
Effectively use all methods of communication and be aware of and manage barriers to communication. Effectively recognise and manage challenging behaviours, carers and or relatives. Provide information to patients, their carers and/or relatives on behalf of the team. The PCN will ensure the PCNs Care Coordinator for Inequalities and Access can discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g.
abuse, domestic violence and support with mental health) with a relevant GP. Supporting Care Delivery Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated. Follow through actions identified by MDTs or individual primary care professionals including arranging tests, referrals, signposting, etc. Follow through with service users and others involved to ensure all services and care arrangements are in place.
Autonomy/Scope within Role The post holder will be required to work within clearly defined organisational protocols, policies and procedures. Special Working Conditions The post-holder is required to travel independently between Tone Valley PCN GP practice sites (where applicable), and to attend meetings etc. hosted by other agencies. Job Description Agreement This job description is an outline of the key tasks and responsibilities of the post and the post holder may be required to undertake additional duties appropriate to the pay band.
The post may change over time to reflect the developing needs of the PCN and its services, as well as the personal development of the post holder.
