Care Coordinator/HCA

The Care Coordinator/HCA role is seen as a critical and evolving post to support the multi-disciplinary teams (MDTs) within the PCN to deliver effective, co-ordinated and personalised care for patients in care homes and for a cohort of elderly and frail patients. Care Coordinator/HCA play an important role within a PCN to proactively identify and work with people, including the frail/elderly, LD, SMI and those with long-term conditions to provide coordination 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. Previous HCA skills would be beneficial. Full training given to right candidate.

Main duties of the job:

• Proactively identify and work with a cohort of patients to support their personalised care requirements.
• Provide coordination and navigation support using digital tools to help patients access appropriate services.
• Develop and maintain personalised care and support plans based on an individual's needs and what matters to them.
• Promote preventative health care and continuity of care.
• Carry out and record observations or temperature, blood pressure and pulse, reporting to qualified staff.
• Maintain standards of accurate record keeping by documenting all care given in the patient's record as directed.

About us:

York City PCN is delighted to offer a great opportunity for a highly motivated Care Coordinator who wishes to develop their career within an exceptional primary care environment. York City Primary Care Network (PCN) are two innovative GP practices Jorvik Gillygate and Dalton Terrace which are both situated within the York ring road. Our fantastic clinical team includes GPs, ACPs, Pharmacists, Physician Associates, Nurses, HCAs and Social Prescribes.

Job responsibilities:

• 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 ensure that people have good quality written or verbal information to help them make choices about their care.
• Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
• Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the person's care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
• 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 decision-making conversations.
• Take referrals or proactively identify people who could benefit from support through care coordination.
• Have positive, empathetic and responsive conversations with people and their families and carer(s), about their needs.
• Develop an in-depth 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 managing their health and tailor support to them accordingly.
• Review and update personalised care and support plans at regular intervals.
• Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person's care and uploaded to the relevant online care records.
• Make and manage appointments for patients, related to primary care.
• Refer onwards to social prescribing link workers and health and wellbeing coaches where required and to clinical colleagues where there is an unaddressed clinical need.
• Identify when action or additional support is needed, alerting a named contact in addition to relevant professionals, and highlighting any safety concerns.
• Work with your supervising GP to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.
• Involved in one-to-one meetings with line manager regularly to discuss targets and outcomes achieved.
• Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
• Adhere to organisational, practices and PCN policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.

Person Specification:

• Experience of working with the general public.
• Previous HCA Experience.
• Experience of working in primary care.
• Experience of working in a health care setting.
• Personalised Care Plan and supporting patients to navigate services.
• Assisting with chronic disease reviews.
• Health promotion including weight, height and lifestyle advice.

Qualifications:

• GCSE grade A to C in English and Maths.
• Qualified to NVQ level 2 in Health and Social Care.

Knowledge and skills:

• Excellent communication skills (written and oral).
• Clear, polite telephone manner.
• Effective time management (Planning & Organising).
• Ability to work as a team member and autonomously.
• Good interpersonal skills.
• Problem solving & analytical skills.
• Ability to follow policy and procedure.
• Competent in the use of Office and Outlook.

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.