PCN Care Coordinator

About Us The Confederation, Hillingdon CIC works with General Practice and other healthcare providers to deliver its vision for “Hillingdon to deliver the best primary care outcomes for patients in the whole of London”. We are a not-for-profit community interest company. The Confederation works to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We deliver excellent clinical services ourselves both at scale and complementary to General Practice. We are the provider representative voice for local General Practice into the wider NHS and other Partners. We are ‘of the NHS’ but independent, innovative and transformational. About Us The Confederation, Hillingdon CIC works with General Practice and other healthcare providers to deliver its vision for “Hillingdon to deliver the best primary care outcomes for patients in the whole of London”. We are a not-for-profit community interest company. The Confederation works to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We deliver excellent clinical services ourselves both at scale and complementary to General Practice. We are the provider representative voice for local General Practice into the wider NHS and other Partners. We are ‘of the NHS’ but independent, innovative and transformational. The Confederation determines to develop as an attractive place to work, providing rewarding roles and opportunities to grow in order to attract and retain great staff that in turn delivers our vision. Our Values Job Summary: An exciting opportunity has arisen within Primary Care to work as a Care Coordinator at The Confederation, Hillingdon CIC. Care 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 people and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a person’s 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 person. Care Coordinators could provide time, capacity and expertise to support people in preparing for, or following-up, clinical conversations. Enabling them to be more actively involved in managing their care and supporting them to make choices that are right for them. Care Coordinators help people improve their quality of life. The successful candidate will be caring, dedicated, reliable, person‑focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support. This role is intended to become an integral part of the PCN’s multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all‑encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN. Please note that the Care Coordinator works under delegation of a registered health professional. Primary Responsibilities The role will be to work within our network of GP Practices to provide a central coordination role for patient care planning as well as: * Work with people, their families and carers, to improve their understanding of their condition. * Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. * Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. * Assist people to access self‑management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health. * Provide coordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined‑up service and the appropriate support from the right person at the right time. * Work 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 PCN. * Support the coordination and delivery of multidisciplinary teams with the PCN. * Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision‑making conversations. Key Tasks Enable Access to Personalised Care and Support: * Take referrals or proactively identify people who could benefit from support through care coordination. * Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs. * Increasing patients’ understanding of how to manage and improve health and wellbeing by offering advice and guidance. * Develop an in‑depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them. * Use tools to measure people’s levels of knowledge, skills and confidence in managing their health and tailor support to them accordingly. * Support people to develop and implement personalised care and support plans. * Review and update personalised care and support plans at regular intervals. * Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person’s care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes. Coordinate And Integrate Care * Make and manage appointments for patients, related to primary care. * Help people transition seamlessly between secondary and community care services, conducting follow‑up appointments, and supporting people to navigate through the wider health and care system. * Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need. * Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the person’s care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported. * Actively participate in multidisciplinary team meetings in the PCN. * Identify when action or additional support is needed, alerting a named contact in addition to relevant professionals, and highlighting any safety concerns. * Record what interventions are used to support people, and how people are developing on their health and care journey. Professional Development * Work with your supervising GP and/or line manager (if different) to undertake continual personal and professional development, taking an active part in reviewing yearly progress, and developing the roles and responsibilities and developing clear plans to achieve results within priorities set by others. * Work with your supervising GP to access regular ‘clinical supervision’, to enable you to deal effectively with the difficult issues that people present. * Involved in one‑to‑one meetings with line manager regularly to discuss targets and outcomes achieved. Miscellaneous * Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each other’s views and meeting regularly as a team. * Act as a champion for personalised care and shared decision making within the PCN. * Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner. * Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning. * Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities. * Adhere to organisational, practices and PCN policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. * Contribute to the wider aims and objectives of the PCN to improve and support primary care. Health & Safety/Risk Management * The post-holder must comply at all times with all local Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System. * The post-holder will comply with the Data Protection Act (1984) and the Access to Health Records Act (1990). Equality & Diversity * The post-holder must co‑operate with all policies and procedures designed to ensure equality of employment. Co‑workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc. Patient Confidentiality * The post holder must at all times respect patient confidentiality and, in particular, the confidentiality of electronically stored personal data in line with the requirements of the General Data Protection Regulation and in keeping with Hillingdon Primary Care Confederation Information Governance Policy and procedures. * The post holder should not divulge patient information unless sanctioned by the line manager and required for the role. Job Description Agreement This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to take into account development within The Confederation. All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the service or function. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder. Person Specification Essential Criteria * Ability to actively listen, empathise with people and provide personalised support in a non‑judgemental way * Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity * Commitment to reducing health inequalities and proactively working to reach people from diverse communities * Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential * Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders * Ability to identify risk and assess / manage risk when working with individuals * Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role – e.g. when there is a mental health need requiring a qualified practitioner * Ability to maintain effective working relationships and to promote collaborative practice with all colleagues * Ability to demonstrate personal accountability, emotional resilience and work well under pressure * Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines * Ability to work flexibly and enthusiastically within a team or on own initiative * Demonstrable commitment to professional and personal development * Completed a two day PCI accredited care coordination training course or be willing to complete one prior to taking referrals. * Proficient in MS Office and web -based services * Excellent interpersonal, influencing and negotiating skills. * Excellent written and verbal communication skills * Strong organisational skills, including planning, prioritising, time management and record keeping * Able to adhere to legal, ethical, professional and organisational policies/procedures and codes of conduct. * Ability to travel across the locality on a regular basis Desirable Criteria * Ability to provide motivational coaching to support people’s behaviour change * Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement * Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity) * Experience of working within multi - professional team environments * Experience of supporting people, their families and carers in a related role * Experience or training in personalised care and support planning * Experience of data collection and using tools to measure the impact of services * Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation * Understanding of personalised care and the comprehensive model of personalised care * Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers J-18808-Ljbffr