About this role
Job summary
This role is to support the smooth co-ordination of patient care for Practices within the Primary Care Network for the benefit of our patients.
The Care Coordinator will be responsible for consulting with patients and determining their needs, developing care plans, coordinating patient-care service, empowering them to be independent whenever possible and working with the Practice and care teams to evaluate interventions and support MDTs.
Main duties of the job
To work at one base within a Primary Care Network To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely, by telephone or video Liaise with Care Homes as necessary
About us
About Alliance for Better Care CIC
Alliance for Better Care (ABC) is a GP Federation uniting 77 NHS GP member practices across 98 sites within 24 Primary Care Networks in Sussex and Surrey. We support our Primary Care colleagues - and their patients - to transform how healthcare is delivered in their communities.
We work closely with GP Practices, PCNs, Hospitals, Community Organisations, and the Third Sector. These vital partnerships enable us to deliver a truly integrated approach that offers the support and expertise needed to effectively serve our populations.
About Haywards Heath Central PCN
Haywards Heath Central Primary Care Network is an NHS Collaboration between two GP Practices Dolphins Practice and Newtons Practice - working together to provide enhanced access services.
Our surgery teams work closely, sharing expertise and resources to develop new services. Our vision is to continue to improve the quality of care that we provide in alignment with the needs of our patient population.
Our Primary Care Network builds on the existing primary care services and enables a greater provision of proactive, personalised and more integrated health and social care. We are supported by practitioners in additional roles who allow us to create bespoke multi-disciplinary teams based on the needs of our local population. By working together with local community services, this allows us to make support available to people where it is most needed.
Job description Job responsibilities
MDT Coordination
Overall responsibility for arranging and attending MDT meetings and the smooth running of integrated care within the medical centre. A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meetingIdentify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditionsCare Co-ordination
Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligenceHelp patients understand their condition by liaising with clinical colleagues, especially the practice pharmacy team, regarding their medicationWith the help of relevant clinical colleagues, develop a care plan to address patients personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including EMIS and ShareMyCarePromote clear communication amongst Practice care team and treating clinicians by ensuring awareness regarding patient care plansAssist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plansLinking with other services
Signpost patients, carers and team members, to relevant services including the PCN Social Prescribing Link Worker ServiceLiaise with the Social Prescriber and Mental Health Support Coordinator regarding patients that are identified as needing well-being supportLiaise with practice clinicians responsible for frailty regarding patients that are identified as needing ongoing supportLiaise with acute trusts, care homes, hospices, community service and social care providers as requiredMake referrals to support patient independence and care to agencies within remits and with patient consentRecord Keeping
Keep accurate and up-to-date records of contact with patients, carers and professionals, including use of EMIS to record patient contact on the medical record, including care home visitsUse accurate SNOMED codes to record patient contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomesManage reporting required and associated within the DES specifications for required servicesGeneral Responsibilities
Work as part of the team to seek feedback, continually improve the service and contribute to business planningUndertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective mannerAttend ongoing training and courses to keep abreast of new developments in health careTreat patients with empathy and respect and conduct oneself in a professional mannerAttend and contribute to relevant meetingsDuties may vary from time to time, without changing the general character of the post or the level of responsibilityReports to: Operations Manager
Responsible to: PCN Clinical Director
Proposed salary:Band 4.3 - 4.7 on the ABC pay scale which is equivalent to £24,904.78 - £26,957.74 per annum dependent on experience, pro rata
Tenure: Permanent
Hours of work: 30 hours
Base: The successful candidate will be based predominantly at Newtons Practice but there may be a need to cross cover to support both Core Network Practices as needed
Benefits
Generous annual leave allowanceAccess to NHS pensionBespoke training programmeCycle to Work SchemeEmployee Assistance ProgrammeEnhanced maternity payNHS discountsLeadership Development ProgrammeSalary sacrifice schemes technology and electric vehicleOpportunities for secondmentsFor further information please see the full job description.
Person Specification
Skills and Abilities Essential
Able to listen, empathise with people and provide person- centred support in a non-judgemental way Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity Committed to reducing health inequalities and proactively working to reach people from all communities Able to support people in a way that inspires trust and confidence, motivating others to reach their potential Able to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders Able 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 e.g. when there is a mental health need requiring a qualified practitioner Able to provide initiate, follow up and finish work tasks Able to maintain effective working relationships and to promote collaborative practice with all colleagues Demonstrates personal accountability, emotional resilience and works well under pressure Able to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines High level of written and oral communication skills Excellent IT skills including Excel as well as knowledge of GP clinical systems, experience of data entry and coding
Qualifications Essential
Grade 4 or above GCSE Maths and English
Desirable
NVQ Level 3, Advanced level or equivalent qualifications or working towards Training in motivational coaching and interviewing or equivalent experience
Knowledge and Experience Essential
Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
Experience of working directly in either the NHS or Adult Social Care
Behaviours and Values Essential
Able to work flexibly and enthusiastically within a team or on own initiative Demonstrable commitment to professional and personal development with a can-do attitude
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 Alliance for Better Care CIC
Address Newtons Practice
Heath Road
HAYWARDS HEATH
West Sussex
RH16 3BB
United Kingdom
Employer's website https://allianceforbettercare.org/ (Opens in a new tab)