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non title Wadebridge, England

North Cornwall Coast PCN

Full Time Wadebridge, England 10.56 - 12.04 GBP Today

Job description

Care Co-Ordinator

North Cornwall Coast PCN are seeking an enthusiastic and proactive Care Co-Ordinator to join our team. We are a patient focused forward thinking PCN looking for people to work with the PCN team to deliver care to their patient populations. The Care Co-Ordinator role is an evolving role within NHS Primary Care Networks. The post holder will require a flexible approach to work, the role will consist of some focussed project work as well as general core support to the PCN. The post holders would ideally have good knowledge of community or primary care sector and good IT skills.

JOB PURPOSE

The Care Co-Ordinator role is seen as a critical and evolving post to support the multi-disciplinary teams (MDTs) within the PCN to deliver effective, co-ordinated and personalised care for patients in care homes and for a cohort of elderly and frail patients.

The post holder will work closely with teams to help and support the multi-disciplinary team (MDT) this will include the on-going patient case management. This will involve working with the GP surgeries and linking in with a range of community health and social care services, care homes and third-party services to assess the ongoing needs of patients in their own homes.

The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. The post holder must at all times be aware of the need for confidentiality and integrity. They will also need a basic knowledge of Health and Social Care terminology and eligibility criteria and current team structures and pathways.

To provide minor assessments of the patient and their needs to maintain safe living at home. Assessing the needs for care packages and Supporting with the referrals of equipment and technology,

Key working relationships

Patients, patients families and carers

GPs, nurses and other practice staff

Care home managers, clinicians, carers and staff

Case Manager and Geriatrician

Community nurses and other allied health professionals

Community pharmacists and support staff

Cornwall Council Staff and equipment specialists

Responsibilities underpinning the role

The Care Co-Ordinator has the following key responsibilities, in delivering health services:

To assist the team to develop one single personalised care and support plan for patients to be held on the patient’s medical records and in the care homes. Holistically bring together all of a patient’s identified care and support needs, and explore options to meet these with a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.

Help patients to manage their needs by answering queries, assisting with making/ managing appointments, and ensuring that patients have good verbal or written information to help them make choices about their care.

Provide coordination and navigation for patients and their carers across health and social care services, working closely with social prescribing link workers and other primary care professionals. Explore and assist people to access personal health budgets or appropriate benefits where eligible.

Assessment of patients in their own homes who are struggling with managing their day to day living, liaising with loan stores, district nurses and Technical officers to improve safety and wellbeing.

Support patients to utilise decision aids in preparation for a shared decision making conversation.

Work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the PCN.

Raise awareness within the PCN of shared decision making and decision support tools. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations.

To act as first point of contact for professionals, GPs, care homes, community services and the third sector.

Responsible for the organisation of MDT meetings and supporting the coordination and delivery of MDTs within the PCN.

To take a lead in IT ensuring all MDT staff have access to ‘Microsoft Teams’ and have adequate equipment to participate in video meetings.

To act as a support contact for elderly and frail patients.

To follow appropriate safeguarding procedures.

Administrative Responsibilities

To work as a key member of the MDT to help support the development of effective MDT meetings.

To update care plan templates within EMIS ensuring accuracy with read codes used.

Lead on the IT facilitation of the MDT meetings using Microsoft teams including sending out invites to appropriate members of the MDT.

To take minutes of MDT meetings and ensure that action points identified are recorded and followed up within a set timescale.

Under guidance from their line manager take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team.

Act as a non-clinical contact for the care home to assist with case management of patients at risk of admission; working with the ANP / GP to identify sources of support in liaison with case managers.

To work with the wider MDT to identify appropriate case managers* for high risk patients to ensure that patients are reviewed and anticipatory care plans are developed

Ensure that all patients’ Anticipatory Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available

To liaise with acute hospitals and coordinate the sharing of key information between the acute hospital teams and the MDT team.

Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute / community hospital setting

Workforce Responsibility

The post holder must remain up to date with mandatory training as required

Environmental Factors

The post holder will be required to drive

The post holder may be required to undertake duties at any location in the community in order to meets service needs

Concentration required for data analysis, tracking patients and meetings, frequent interruptions requiring attention and re-prioritisation of work

Input data for a significant period

CODES OF CONDUCT

Equal Opportunities

North Cornwall Coast PCN is committed to an equal opportunities policy that affirms that all staff should be afforded equality of treatment and opportunity in employment irrespective of sexuality, marital status, race, religion/belief, ethnic origin, age or disability. All staff are required to observe this policy in their behaviour to fellow employees.

Confidentiality

All employees are required to observe the strictest confidence with regard to any patient/client information that they may have access to, or accidentally gain knowledge of, in the course of their duties.

All employees are required to observe the strictest confidence regarding any information relating to the work of North Cornwall Coast PCN and its employees. You are required not to disclose any confidential information either during or after your employment with North Cornwall Coast PCN, other than in accordance with the relevant professional codes.

Failure to comply with these regulations whilst in the employment of North Cornwall Coast PCN could result in action being taken.

Data Protection

All employees must adhere to the North Cornwall Coast Policy on the Protection and use of Personal Information, which provides guidance on the use and disclosure of information. The practices of North Cornwall Coast also have a range of policies for the use of computer equipment and computer-generated information. These policies detail the employee’s legal obligations and include references to current legislation.

Health and safety

North Cornwall Coast expects all staff to have a commitment to promoting and maintaining a safe and healthy environment and be responsible for their own and others welfare.

Risk management

You will be responsible for adopting the risk management culture and ensuring that you identify and assess all risks to your systems, processes and environment and report such risks for inclusion within the risk register of the practices of North Cornwall Coast PCN. You will also attend mandatory and statutory training, report all incidents/accidents, including near misses, and report unsafe occurrences as laid down within the Incidents and Accidents Policy.

Job Types: Full-time, Part-time, Permanent

Schedule: