About this role
Job summary
The Care Coordinator role is seen as a critical and evolving post to support [the Enhanced Health in Care Homes (EHCH) Multi-Disciplinary Teams within the locality to deliver effective, coordinated care for vulnerable and frail adults, particularly those at high risk of a hospital emergency admission, ED attendances or out of hours care.
To proactively coordinate personalised care and support planning for the most vulnerable people in the community, focussing on the frail/elderly and those with other long-term health conditions.
To meet with people, families and carers (in the practice, in their home and in other community settings) to co-ordinate their care, review their needs and help them access the services and support they require, assisting them to understand and manage their own health and wellbeing referring to other professionals where appropriate.
Act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. 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 person.
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Main duties of the job
Support the PCN in bringing together all of a patients 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 patient. This may include having a caseload of patients.
Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system
Support the frailty team in identifying appropriate patient cohorts for targeted intervention
Partake in multidisciplinary meetings across local care organisations identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.
Provide admin support to multidisciplinary meetings including taking minutes.
Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists, and other support staff from within the PCN practices or from other provider organisations
Undertake delegated clinical procedures within own skills and competence when required (depending on experience and qualifications)
Assist patients and carers in managing their own needs, answering their queries, and supporting them to address their needs
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About us
LS25/26 PCN has a patient population of approximately 77,500 across 7 practices. We aim to provide high quality services adhering to principles of best practice, promoting equal opportunities, and working positively with diversity.
Job description Job responsibilities
Location - LS25/26 PCN - 7 Practices
The Care Coordinators role will support the frailty team and Multi-Disciplinary Team in coordinating all key activity including access to services, advice, and information, helping them to live well at home. This role will also include some clinical aspects, such as observations, venepuncture, skin checks etc.
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Person Specification
Experience Essential
Experience of working in health, social care, and other support roles in direct contact with people, families, or carers Has attention to details, able to work accurately, identifying errors quickly and easily Has a planned and organised approach with an ability to priority their own workload to meet strict deadlines Understanding of medical technology around frailty, population health management, and long-term conditions Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience An excellent understanding of data protection and confidentiality issues Able to arrange suitable meetings with multiple individuals with often conflicting priorities Self-motivated and pro-active Continued commitment to improve skills and abilities in new areas of work Able to undertake the demands of the post with reasonable adjustment if required Able to access transport to work across the practices within the PCN and attend meetings in other locations Excellent time keeping and prioritisation skills Professional attributes and appearance
Desirable
Administrative duties including preparing for meetings and writing minutes Working knowledge of SystmOne Understanding of the current issues facing the NHS including Primary Care Networks Venepuncture Clinical observation (BP,Temperature, heart rate) Measuring and ordering equipment for example, pressure cushions, walking sticks etc
Qualifications Essential
GCSEs/Diploma/HNC level (or relevant experience)
Desirable
NVQ Level 3 in a health or social care related discipline (or relevant experience) Care Certificate ECDL or other equivalent IT qualification
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 Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Employer details Employer name South and East Leeds GP Group
Address 1st Floor Park Edge Practice
Asket Drive
Leeds
West Yorkshire
LS14 1HX
United Kingdom
Employer's website https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)