Care Coordinator inSheffield inSheffield PUBLISHED 23 OCT 2024

We are looking for a network Care Co-ordinator to join our network

An exciting opportunity has arisen for a Care Coordinator to join our developing multidisciplinary teams across Porter Valley Network.

We are looking for a compassionate, collaborative and motivated care coordinator to support the delivery of care to vulnerable patients and referred to our social prescribing hub, coordinating the work of social prescribing professionals and the wider social and voluntary care sectors in our area.

You will be an essential part of a dynamic and forward-thinking multidisciplinary team spanning practices and our Primary Care Mental health team.

Salary £21,892.00-£25000 FTE dependant on experience

FTE 37.5 hours

Primary Duties and Areas of Responsibility

1. Triage and help patients referred to our social prescribing hub

2. Liaise and work with our wider social prescribers

3. Coordinate our patients waiting for assessment by our Primary Care Mental health team

4. Coordinate our at scale public heath work on health promotion and cancer care support

5. Coordinate our wider community MDT and develop our integrated neighbourhood working

6. Develop new projects like our peer support groups

About us

The Care Co-ordinator will work flexibly across all 6 GP Surgeries in the Porter Valley Primary Care Network (PCN). You will be part of a large multidisciplinary team which supports a population of approximately 43,000 patients. This role is pivotal to ensuring that all patients receive the best possible care and service.

Utilising population health intelligence for the network you will proactively identify and support a cohort of patients to ensure access to personalised care; holistically bringing together all of a persons identified care and support needs, exploring options to meet these within a single personalised care and support plan in line with best practice, based on what matters to the person. You will also work with patients identified for support by clinicians and referred into the Health and wellbeing Hub across the network.

Providing advice and information, ensuring improved efficient patient access to services through timely health and care planning. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care. This will require an ability to change focus as required and management of different projects as the Networks are directed by NHSE.

The PCNs Core Network Practices will identify a first point of contact for general advice and support to provide you with supervision, this could be provided by one or more named individuals within the PCN. You will have the opportunity to discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with a relevant GP.

You will also support the PCN team in coordinating all key activity required to meet the delivery of the QOF QI, IIF and the PCN DES contract specifications. This will require you to remain up to date with new requirements and take a lead in monitoring progress and supporting practice and the network in making progress towards the required achievements.

Main duties of the job

• working with the Network to ensure that the requirements of the Network DES Service Specifications, Investment and Impact fund and Quality Outcome framework and quality indicators are met. This will require a change in focus and management of different projects as the Networks are directed by NHSE and will require flexibility on the part of the applicant.
• The Care Co-ordinator will identify patients from population intelligence within the network and signpost to the appropriate health and social support as required, ensuring care is co-ordinated and delivered timely, effectively and efficiently in line with Primary Care Service requirements.

• Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing
• Manage and prioritise own workload on a daily basis and deal with the competing demands.
• Assist the network to meet the changing needs of the service, ensuring aware of up to date demands and requirements of the network

Job Role and responsibilities:

The Care Co-ordinator will:

• utilise population health intelligence to proactively work with the MDT to ensure they are aware and notified of patients that would benefit from access to personalised care. Supporting a move to proactive patient support.

• work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN and/or utilise services provided across the neighbourhood.

• raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.

• bring together all of a persons identified care and support needs from digital information, and explore options to meet these into a single personalised care and support plan, using excellent communication and organisational skills to liaise with other stakeholders as needed for the collective benefit of the patients.

• help people to manage their needs through answering queries, signposting to relevant services and ensuring that people have good quality written or verbal information to help them make choices about their care.

• Identify patient need and assist to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.

• signpost people to gain access for personal health budgets where appropriate.

• provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals.

• Ensure awareness of and basic safeguarding processes are in place for vulnerable individuals.

Communication and Interpersonal skills

• communicate effectively across a wide range of channels and with a wide range of individuals, the public, health and social care professionals, and colleagues maintaining the focus of communication on delivering and improving health and care services.
• demonstrate inter-personal skills that promote clarity, compassion, empathy, respect and trust.
• ensure all patient related information is treated sensitively and adhere to the principals of confidentiality at all times.
• report any accidents or incidents and raise any concerns as per organisational policy.
• ensure clear, concise, accurate and legible records and all communication is maintained in relation to care delivered adhering to local and national guidance.
• attend and contribute to meetings within the Network as required.

Care Co-ordinator Responsibilities:

• Ensure all mandatory training is completed on an annual basis including; safeguarding, confidentiality, equality and diversity, Cardio-pulmonary resuscitation etc.
• Ensure infection control guidelines are maintained.
• Work with a supervisor to take responsibility for developing own practical and theoretical competence, developing own reflective practice skills.
• Contribute towards developing a culture of continued learning and innovation, supporting continuous improvements in care delivery.
• Adhere to legislation, policies, procedures and guidelines both local and national, regularly attending workplace and staff engagement meetings.
• Maintain accurate and contemporaneous patient health records
• Work in an effective and organised manner demonstrating excellent time management and organisational skills to effectively deliver person-centred care for an allocated group of individuals