About this role
Job summary
Care Coordinators play an important role within our PCN, working closely with our GP practice teams, Frailty Nurses, Social Prescribing Link Workers, and community services. They work together within the Frailty Team, identifying and managing a caseload of identified patients, making sure that appropriate support is made available to them and their carers. 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.
Main duties of the job
Undertake home visits to have supportive discussions with frail patients and their families, capturing their care and end of life wishes.
Liaise with the Frailty Nurses, GPs and Social Prescribers to ensure that patients are supported to stay well at home.
Undertake BP readings as part of wellbeing checks.
Develop strong relationships with Secondary Care, community and voluntary sector partners.
About us
Cheltenham Central PCN comprises five Practices in the heart of Cheltenham, and was awarded PCN of the Year in 2023. PCN staff enjoy supportive supervision, an open-door policy and an investment in staff wellbeing and progression.
Job description Job responsibilities
In coordination with the Frailty Team, undertake home visits to see patients in their homes, capturing their wishes and what matters to them.
Provide coordination and navigation, and support referrals for people and their carers across health and care services, working closely with community services and other members of the Primary Care team, helping to ensure patients receive a joined-up service and the most appropriate support.
Manage a caseload of referred patients approaching End of Life, and proactively identify a cohort of people in need of anticipatory care, using local knowledge and population health intelligence
Support the organisation, coordination and delivery of multidisciplinary teams (MDTs) with the PCN
Attend the MDTs and be the key person for ensuring regular attendance from nominated representatives or their deputies for each service
Ensure MDT actions are recorded appropriately and followed-up within the defined timescales agreed at the MDT meetings
Improve continuity of care by acting as a point of contact for patients, families and professionals, such as MDT members and in-reach specialists
Bring together a persons identified care and support needs and explore their options to meet these in a single personalised care and support plan
Ensure that people have good quality information to help them make choices about their care and structure conversations using a coaching approach
Person Specification
Experience Essential
Care co-ordinators: Are caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. Have good written, IT and verbal communication skills and strong organisational and time management skills. Are 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.
Desirable
Have a driving license and access to a vehicle Have experience of working in Primary Care
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 Underwood Surgery
Address 139 St. Georges Road
Cheltenham
Gloucestershire
GL50 3EQ
United Kingdom
Employer's website https://underwoodsurgery.co.uk/ (Opens in a new tab)