Care Coordinator inBootle inBootle PUBLISHED 9 JUN 2024

Midlands and Lancashire Commissioning Support Unit

Support people to understand their level of knowledge, skills, and confidence, when engaging with their health and wellbeing.
Job Overview


Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.

They can be an effective intervention in supporting people to stay well particularly those with long term conditions, multiple long-term conditions, and people living with or at risk of frailty.


Please note this role is not eligible for Vacancy Sponsorship.



Main duties of the job


Working closely with GPs, Community Services, Care Homes and Practice Teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to patients and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. We are seeking Care Coordinators to work in the following service areas: Enhanced Health at Home.


Key Responsibilities


  • Work with people, their families, and carers to improve their understanding of the patient’s condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes
  • Help people to manage their needs through answering queries, making, and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care
  • Support people to understand their level of knowledge, skills, and confidence, when engaging with their health and wellbeing
  • Work as part of the multidisciplinary team, building relationships with staff in GP practices within the PCN, care homes & other organisations.



Working for our organisation



Within South Sefton PCN Our Aims Are To


  • Improve resilience in General Practice
  • Build a stronger and more sustainable general practice service across the Primary Care Network footprint
  • Facilitate collaborative working between all Primary Care Network practices
  • Engage with local health and care providers to develop place-based care to assist in the transformation of local services to improve the health and wellbeing of the Primary Care Network population
  • Work with Patient Participation Groups to improved patient access, experience and quality
  • Reach out to strengthen and develop working relationships with non-NHS community groups
  • Develop signposting with Primary Care Network practices to streamline the patient journey to enhance more achievable and sustainable outcomes
  • Further develop digital technology as a primary resource for practices and patients
  • Work in collaboration with the local GP Federation to build and strengthen relationships



Detailed Job Description And Main Responsibilities


As Care Coordinator your key responsibilities will include, but not be limited to:

Multidisciplinary Team (MDT)

  • Arrange the EHAH led Huddles/MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified,


and information circulated to team members in advance of the meeting. Record actions agreed at the meetings or take minutes and

circulate as required.

  • Consult with all members of the MDT to ensure its effective function.
  • Work closely within the PCN roles, Community Services, Community Matron, MDT and with GP practices within the PCN to ensure that


the comprehensive records of MDT case discussions are entered into clinical systems, adhering to data protection legislation and data

sharing agreements.

  • Work as part of the MDT and wider PCN / Care Community to achieve its ICP (integrated care provider) directed objectives.


Referrals

  • As part of the PCN MDT, build relationships with staff in each GP Practice within the PCN, attending practice meetings as required providing information and feedback on care coordination priorities.
  • Consult directly with Community services, Acute Trust Ward Managers, Social Care, Practice staff and other key providers to identify


patients for discussion at MDT, and compile and circulate relevant information to attendees.

  • Refer patients to local services as required utilising providers referral processes.


Working with patients

  • Using clinical systems and data analysis to ensure a proactive approach to identifying patients that would benefit from review.
  • Alerting, referring or liaising with the relevant Service, Community Matron, professionals, family, and other services as required.
  • Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision making conversation.
  • Work with patients, Carers, and professionals to deliver personalised care and support planning for patients.
  • Help people to manage their needs through answering queries, making, and managing appointments and ensure that patients have excellent quality information to help them make choices about their care.
  • Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including


through use of the tools.

  • Provide co-ordination and navigation for patients and their carers across health and care services, consulting with practice and PCN staff


including social prescribing link workers and health and wellbeing coaches.

  • Seek advice and support from the Community Matron/GP supervisor/Clinical Lead and/or identified individual(s) to discuss patient related concerns (e.g. abuse, domestic violence, and support with mental health), referring the patient back to the GP or other suitable


health professional if required.

  • To manage communications and social media pages to ensure patients have relevant and timely information to help them manage their health needs.

    Job Overview

    Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.

    They can be an effective intervention in supporting people to stay well particularly those with long term conditions, multiple long-term conditions, and people living with or at risk of frailty.

    Please note this role is not eligible for Vacancy Sponsorship.


    Main duties of the job

    Working closely with GPs, Community Services, Care Homes and Practice Teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to patients and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. We are seeking Care Coordinators to work in the following service areas: Enhanced Health at Home.

    Key Responsibilities

    • Work with people, their families, and carers to improve their understanding of the patient’s condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes
    • Help people to manage their needs through answering queries, making, and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care
    • Support people to understand their level of knowledge, skills, and confidence, when engaging with their health and wellbeing
    • Work as part of the multidisciplinary team, building relationships with staff in GP practices within the PCN, care homes & other organisations.


    Working for our organisation


    Within South Sefton PCN Our Aims Are To

    • Improve resilience in General Practice
    • Build a stronger and more sustainable general practice service across the Primary Care Network footprint
    • Facilitate collaborative working between all Primary Care Network practices
    • Engage with local health and care providers to develop place-based care to assist in the transformation of local services to improve the health and wellbeing of the Primary Care Network population
    • Work with Patient Participation Groups to improved patient access, experience and quality
    • Reach out to strengthen and develop working relationships with non-NHS community groups
    • Develop signposting with Primary Care Network practices to streamline the patient journey to enhance more achievable and sustainable outcomes
    • Further develop digital technology as a primary resource for practices and patients
    • Work in collaboration with the local GP Federation to build and strengthen relationships


    Detailed Job Description And Main Responsibilities

    As Care Coordinator your key responsibilities will include, but not be limited to:

    Multidisciplinary Team (MDT)

    • Arrange the EHAH led Huddles/MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified,

    and information circulated to team members in advance of the meeting. Record actions agreed at the meetings or take minutes and

    circulate as required.

    • Consult with all members of the MDT to ensure its effective function.
    • Work closely within the PCN roles, Community Services, Community Matron, MDT and with GP practices within the PCN to ensure that

    the comprehensive records of MDT case discussions are entered into clinical systems, adhering to data protection legislation and data

    sharing agreements.

    • Work as part of the MDT and wider PCN / Care Community to achieve its ICP (integrated care provider) directed objectives.

    Referrals

    • As part of the PCN MDT, build relationships with staff in each GP Practice within the PCN, attending practice meetings as required providing information and feedback on care coordination priorities.
    • Consult directly with Community services, Acute Trust Ward Managers, Social Care, Practice staff and other key providers to identify

    patients for discussion at MDT, and compile and circulate relevant information to attendees.

    • Refer patients to local services as required utilising providers referral processes.

    Working with patients

    • Using clinical systems and data analysis to ensure a proactive approach to identifying patients that would benefit from review.
    • Alerting, referring or liaising with the relevant Service, Community Matron, professionals, family, and other services as required.
    • Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision making conversation.
    • Work with patients, Carers, and professionals to deliver personalised care and support planning for patients.
    • Help people to manage their needs through answering queries, making, and managing appointments and ensure that patients have excellent quality information to help them make choices about their care.
    • Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including

    through use of the tools.

    • Provide co-ordination and navigation for patients and their carers across health and care services, consulting with practice and PCN staff

    including social prescribing link workers and health and wellbeing coaches.

    • Seek advice and support from the Community Matron/GP supervisor/Clinical Lead and/or identified individual(s) to discuss patient related concerns (e.g. abuse, domestic violence, and support with mental health), referring the patient back to the GP or other suitable

    health professional if required.



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