Care Coordinator in Frimley

An exciting opportunity has arisen for a Care Coordinator to join our team at Surrey Heath Primary Care Network (PCN), supporting the delivery of the new Network Contract Direct Enhanced Service (DES) specifications. Hours available: 18 hours per week.

We are looking for a Care Coordinator to support our PCN, working closely with PCN Practices and the multidisciplinary team in coordinating all key activities, including access to services, advice, and information, ensuring health and care planning is timely, efficient, and patient‐centred. The post holder will help patients interact and engage with everyday life through activities designed to develop, maintain, or retrain skills for people with a cognitive, physical, or mental disorder, condition, or illness, support the provision of continuity of care and act as a point of contact for families, residents, and professionals for identified patients in their caseload.

• Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribers, health and wellbeing coaches and other primary care professionals.
• Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
• Support PCN staff and patients to be prepared to have shared‐decision making conversations, utilising decision aids and tools, and support patients to understand their level of knowledge, skills and confidence (their activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure.
• Help people to manage their needs by answering queries, making and managing appointments, and ensuring that people have food quality written or verbal information to help them make choices about their care.
• Support the practice with the Patient Participation Group (PPG).
• Holistically bring together all of a person's identified care and support plan, in line with best practice, based on what matters to the person.
• Support people to take up training and employment, and to access appropriate benefits, education courses, peer support, and/or personal health budgets where applicable.
• Capture key information to enable comprehensive and accurate records of support, inputting these into clinical systems as required and adhering to data protection legislation.

• Experience of working with healthcare professionals and/or previous experience in the NHS or social care.
• Experience coordinating with multiple stakeholders or individuals to meet specified outcomes.
• Experience providing advice/signposting.
• Experience using a patient clinical system such as EMIS.
• Awareness of how and when to signpost.
• Knowledge of safeguarding interventions and an awareness of the Mental Capacity Act.
• Skilled in the use of person‐centred measurement and outcomes delivery.
• Knowledge of a range of local community groups which support wellbeing.
• Awareness of relevant Health and Social Care legislation and a developed knowledge of crisis intervention.
• Experience of undertaking quality improvement activity.
• Sound understanding of disease prevention and the NHS choices website.
• Creative, flexible and sensitive approach to working with people with diverse support needs.
• Ability to motivate people.
• Ability to reflect on and share best practice with peers.
• Able to travel locally as required.
• Passionate about combatting disadvantage and inequality in healthcare.
• Able to work as part of a team.
• 4 GCSEs (C and above) including English and Maths or equivalent.
• Relevant NVQ Level 3 qualification or equivalent.
• Excellent verbal and written communication skills with the ability to communicate effectively at all levels, including with patients, carers, specialist services, GPs and colleagues.
• Good technical literacy with, e.g., Word, Excel, and experience using a clinical system such as EMIS.
• Able to work independently and manage own workload.
• Able to build strong professional relationships.
• Demonstrable experience of effective planning and organisation skills to deliver targets to deadlines.
• Proven record of excellent written communication skills and a high level of health literacy.
• Understanding of social determinants of health and how these can be addressed with patients.
• Able to analyse and interpret information and present results in a clear and concise manner.