The Site Manager will provide direct line management with support from the Cluster Service Manager and Clinical Governance leads.
Location
The Artesian Health Centre and Decima Street Surgery however, based within a cluster/neighbourhood.
The postholder will be required to work 37.5 hours per week Monday to Friday.
Job Purpose
The care coordinator will be involved in supporting the clinical team to
proactively identify and work with patients, including the frail/elderly and those with long-term conditions, to provide proactive, person- centred care planning, helping coordinate care, by bringing together the different specialists whose help that individual might need. This might involve a wide range of services, such as hospital care, community care, social care, housing, and the voluntary sector.
This role has been developed to support the delivery of better outcomes for patients living with multiple long-term conditions, to help them improve the quality of their life, fostering self-care, independence, and patient choice. The care coordinator will be a key contact for such patients, helping them to navigate health and social care. Supporting them to understand and manage their conditions and ensuring their changing needs are addressed.
In line with support provided to other staff groups, there will be networking and training opportunities across the North Southwark
Primary Care Network, to support the development of the care coordinator role within the network, and wider primary care in Southwark.
MAIN DUTIES and RESPONSIBILITIES
Working with Patients
Work with individual patients, their families, and carers, usinga holistic approach, to identify their goals for care, and agree on personalized care and support plans for their care.
Support the delivery of these care plans by co-coordinating input from a range of different professionals and services, and helping patients and their carers/families to navigate across health and social care services.
Work as part of the primary care team, coordinating care between GPs, practice nurses, clinical pharmacists, social prescribing link workers, and health coaches.
Help patients to manage their needs by answering queries, being the first point of contact in the practice, and making and managing appointments.
Support patients to utilize decision aids in preparation for a shared decision-making conversation and ensure that they, and their carers/family, have access to good quality written and verbal information to help them make choices about their care.
Support patients to take up training and employment where appropriate, and to access benefits where eligible.
Help patients to access personal health budgets where appropriate.
Make use of tools such as Patient Activation Measure when engaging with patients.
Help patients to access self-management education courses, peer support, or other interventions that support them in improving their health and well-being.
Undertake regular reviews of the personalized care and support plans developed with patients.
Work in line with national best practices when developing personalized care and support plans.
Work with patients over the phone, in person in the practice, or for those who are housebound where necessary carry out home visits.
Administration
Use practice-level reports to identify suitable cohorts of patients to deliver personalized care.
Provide accurate and timely data to support audit and monitoring of the service, and any data returns as required by the PCN.
Keep accurate and up-to-date records of contacts with patients and their carers/ families in the patient’s GP record and in their care plan.
Follow-up documentation required for care planning from other organizations, making use of Local Care Records where useful.
Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organizations’ communications and patient notes and ensuring care packages are set up.
Collect data on patients/carers for recognized outcome measures and document for service interpretation.
Managing any necessary meetings to support care planning, identifying patients for discussion, organizing the meeting, and circulating required information beforehand as necessary.
Ensure that meeting actions are recorded, disseminated, and followed up in a timely way; so relevant practitioners are aware of meeting decisions and actions/outcomes, and chase for action resolution and update.
Network and develop strong relationships with key organizations involved in the patients’ care planning.
Training & Development
As this is a new role, training and support will be provided by the Primary Care Network. The care coordinators will be encouraged to form an action learning set across the network and will be given protected time for induction, training, and personal development.
Clinical supervision and leadership will be provided within each practice, on a day-to-day basis, and across the network, as a regular meeting/training session.
As part of their personal development, the post holder will be required to undertake appropriate training as set out by the Personalised Care Institute https://www.england.nhs.uk/personalisedcare/supporting- health-and-care-staff-to-deliver-personalised-care/
In order to evaluate the impact of the role and develop it further, there will be a review across the network, led by the network leadership, and the post holder will be required to contribute with their feedback and provision of practice level data, as needed.
Job Types: Full-time, Fixed term contract
Contract length: 6 months
Pay: £12.44 per hour
Benefits:
Cycle to work scheme
Schedule:
Monday to Friday
Work Location: In person
Application deadline: 05/09/2024