Job summaryWe are an 11,000 patient Practice on the Isle of Sheppey in Kent and are looking for a Care Coordinator to join our hard-working dedicated team.You must have an excellent attendance record, be a good timekeeper, able to work under pressure and enjoy working as part of a team. The successful candidate will be flexible, motivated, reliable, conscientious and committed to making a valuable contribution to the team. The successful candidate will be based in the local cluster of GP Surgeries as part of Sheppey Primary Care Network (PCN).Working hours are to be confirmed.Main duties of the jobCare coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.They work closely with GPs and Practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring that their changing needs are being met.This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single, personalised care and support plan, based on what matters to the patient.Care coordinators review patients needs and help them to access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coached, and other professionals where appropriate.Care coordinators could potentially provide time, capacity and expertise to support patients in preparing for, or following up, clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help patients improve their quality of life.About usWe have one main site in Sheerness, with three other branch sites at Eastchurch, Warden Bay & LeysdownJob descriptionJob responsibilitiesKey ResponsibilitiesWork with patients, their families and carers in order to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomesHelp patients to manage their needs through answering queries, making and managing appointments, and ensuring the patients have good quality written or verbal information to help them make choices about their careSupport patients to understand their level of knowledge, skills and confidence when engaging with their health and wellbeingAssist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeingSupport patients who take up training and employment, and to access appropriate benefits where eligibleProvide coordination and navigation for patients and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined up service and the most appropriate supportWork collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCNSupport the coordination and delivery of multidisciplinary teams with the PCNRaise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients and to be more prepared to have shared decision making conversationsExplore and assist patients to access a personal health budget where appropriateKey Tasks1. Enable access to personalised care and supporta. Take referrals for individuals or proactively identify patients who could benefit from support through care coordinationb. Have a positive, empathetic and responsive conversation with the patient and their family and carer(s) about their needsc. Support patients to develop and implement personalised care and support plansd. Review and update personalised care and support plans at regular intervalse. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patients care and uploaded to the relevant online care records, with activity recorded using the relevant codesf. Where a personal health budget is an option, to work with the patient and the local ICB to provide advice and support as appropriate2. Coordinate and integrate carea. Help patients transition seamlessly between services and support them to navigate through the health and care systemb. Refer onwards to social prescribing link workers and health and wellbeing coaches where requiredc. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the patients care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supportedd. Actively participate in multidisciplinary team meetings in the PCN as and when appropriatee. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concernsThis post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975, and as such it will be necessary for a submission for disclosure to be made to the Disclosure & Barring Service (formerly CRB) to check for any previous criminal convictions.CommunicationThe post holder should recognise the importance of effective communication within the team and will strive to:Communicate effectively with other team membersCommunicate effectively with patients and carersRecognise peoples needs for alternative methods of communication and respond accordinglyConfidentialityIn the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive dataQualitiesThe post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar workHealth & SafetyThe post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety policy, the Health & Safety manual, and the Practice Infection Control policy and published procedures. This will include:Using personal security systems within the workplace according to practice guidelinesIdentifying the risks involved in work activities and undertaking such activities in a way that manages those risksMaking effective use of training to update knowledge and skillsUsing appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazardsActively reporting of health and safety hazards and infection hazards immediately when recognisedKeeping own work areas and general/patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the post-holders roleUndertaking periodic infection control training (minimum annually)Reporting potential risks identifiedDemonstrate due regard for safeguarding and promoting the welfare of childrenEquality & DiversityThe post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with Practice procedures and policies and current legislationRespecting the privacy, dignity, needs and beliefs of patients, carers and colleaguesBehaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rightsThis job description is a reflection of the current position and may change in emphasis or detail in the light of subsequent development, in consultation with the post holder.Person SpecificationPersonal AttributesEssentialAbility to actively listen, empathise and provide personalised support in a non-judgemental way, to inspire trust and confidence and motivate people to reach their potentialAbility to provide a culturally sensitive service, supporting people from all background and communities, respecting lifestyle and diversityCommitment to reducing health inequalities and proactively working with to reach people from diverse communitiesHigh 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 individualsHave a strong awareness and understanding of when it is appropriate to refer back to other health professionals/agenciesAbility to maintain effective working relationships with all colleagues and work flexibly and enthusiastically within a team or working under own initiativeTo promote collaborative workingAbility to demonstrate personal accountability, resilience and work well under pressureAbility to organise, plan and prioritise under own initiative and when under pressure and meeting deadlinesKnowledge of, and ability to work to, policies and procedures including confidentiality, safeguarding, information governance and health and safetyQualificationsEssentialExperience of working within healthcareRegistered General Nurse (degree level)Commitment to professional developmentExperience of working with multi-professional team environmentExperience of dealing with public/patientsExperience of supporting people, their families or carers in a related roleExperience of working in accordance with the UKCC Code of PracticeExperience of data collection and using audits to measure the impact of servicesDemonstrable commitment to professional and personal developmentAbility to use Microsoft Office applicationsExperience or training in personalised are and supportExperience in Chronic Disease ManagementCurrent emergency resuscitation training certificateExperience of EMIS Web clinical systemExperience of Docman10Experience of infection prevention and control measuresKnowledge & SkillsEssentialStrong organisational skills including planning, prioritising, time management and record keepingStrong IT skills to include EMIS, Docman, Word, Excel and experience of using databasesAbility to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients, including GPs, Practice Nurses, healthcare professionals and other staffUnderstanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carersUnderstanding the needs of older people/adults with disabilities/long-term conditions particularly in relation to promoting independenceBasic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and socialAbility to recognise and work within limits of competence and seek advice when neededWilling to travel across PCN sites if/when requiredFamiliar with local resources and services and how to access themKnowledge of the NHS works, including PCNsKnowledge of safeguarding policies and processesAbility to record accurate clinical notesAbility to work within own scope of practice and understand when to refer to GPBroad knowledge of clinical governanceUnderstanding the importance of evidence-based practiceDisclosure and Barring Service CheckThis post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.Employer detailsEmployer nameSt Georges Medical CentreAddress55 St Georges AvenueSheernessKentME12 1QUEmployer's websitehttps://www.saintgeorgesmedicalcentre.co.uk/ (Opens in a new tab)
