Nhs Care Co-ordinator - Manchester, United Kingdom - Broughton Health Alliance Primary Care Network

Description

JOB TITLE:
CARE CO-ORDINATOR




REPORTS TO:
PCN Manager




HOURS:
TBA per week (Morning / Afternoon / Evening)




SALARY:
Under A.R.R.S. and based on Agenda for Change (up to Band 4)

Job Summary:

Care co-ordinators 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 co-ordination 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.

Knowledge of working in a GP practice is highly desirable.

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 co-ordinators 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 co-ordinators help people improve their quality of life and provide assistance in tackling health inequality issues.

This role is intended to become an integral part of the PCN's multidisciplinary team, working alongside social prescribing link workers to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

There may be a need to work remotely depending on the requirements of the role.

Please note that the care co-ordinator works under delegation of a registered health professional


Key Responsibilities:

• 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 selfmanagement 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 joinedup 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 longterm 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 decisionmaking conversations
• Explore and assist people to access a personal health budget where appropriate.
• Work with people, their families, carers and healthcare team members to encourage effective helpseeking behaviours
• Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies
• Identify carers and help them access services to support them.
• Conduct followups on communications from out of hospital and inpatient services.
• Maintain records of referrals and interventions to enable monitoring and evaluation of the service.
• Support practices to keep care records uptodate by identifying and updating missing or outofdate information about the person's circumstances
• Contribute to risk and impact assessments, monitoring and evaluations of the service
• Work with commissioners, integrated locality teams and other agencies to support and further develop the role

Key Tasks:

Enable access to personalised care and support

• Take referrals or proactively identify people who could benefit from support through care coordination.
• Have a 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 indepth 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 managin