Care Coordinator in Truro

Arbennek PCN is looking for an innovative and highly motivated person to join its team as a Care Coordinator. The role, whilst supporting digital initiatives within the Roseland Surgeries and PCN, will be vital in ensuring that patients receive the best possible care and service, supporting the coordination of all key activity including access to services, advice and information whilst ensuring that patient care planning is patient-centred and timely.

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.

About us:

Arbennek PCN is located in the central ICA within the Cornwall and Isles of Scilly Integrated Care System and has approximately 32,453 people registered from 4 GP Practices: Brannel Surgery, Clays Surgery, Probus Surgery and Roseland Surgeries. The post holder will work a majority of their time out of The Roseland Surgeries.

Job responsibilities:

Job Purpose: The Care Coordinator role is seen as a critical and evolving post to support the multi-disciplinary teams (MDTs) within the PCN to deliver effective, coordinated and personalised care for patients in care homes and for a cohort of elderly and frail patients. The post holder will work closely with teams to help and support the MDT, which will include ongoing patient case management. This will involve working with the GP surgeries and linking in with a range of community health and social care services, care homes and third-party services.

The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. They must at all times be aware of the need for confidentiality and integrity. A basic knowledge of Health and Social Care terminology and eligibility criteria and current team structures and pathways is also required.

Key working relationships:

• Patients, patients' families and carers
• GPs, nurses and other practice staff
• Care home managers, clinicians, carers and staff
• Case Manager and Geriatrician
• Community nurses and other allied health professionals
• Community pharmacists and support staff

Responsibilities underpinning the role:

• Assist the team to develop one single personalised care and support plan for patients to be held on the patients' medical records and in the care homes.
• Help patients manage their needs by answering queries, assisting with making/managing appointments, and ensuring that patients have good verbal or written information to help them make choices about their care.
• Provide coordination and navigation for patients and their carers across health and social care services, working closely with social prescribing link workers and other primary care professionals.
• Support patients to utilise decision aids in preparation for a shared decision-making conversation.
• Work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the PCN.
• Act as the first point of contact for professionals, GPs, care homes, community services and the third sector.
• Responsible for the organisation of MDT meetings and supporting the coordination and delivery of MDTs within the PCN.
• Review discharge summaries and conduct post-discharge follow-up calls to review patients' needs and arrange a package of care if needed.
• Manage the recall of patients in need of bloods/BPs and other diagnostic tests for medication reviews and/or green eclipse alerts.
• Support end-of-life care and palliative care.
• Follow appropriate safeguarding procedures.

Administrative Responsibilities:

• Work as a key member of the MDT to help support the development of effective MDT meetings.
• Take a lead in IT ensuring all MDT staff have access to Microsoft Teams and have adequate equipment to participate in video meetings.
• Lead on the IT facilitation of the MDT meetings using Microsoft Teams including sending out invites to appropriate members of the MDT.
• Take minutes of MDT meetings and ensure that action points identified are recorded and followed up within a set timescale.
• Work with the wider MDT to identify appropriate case managers for high-risk patients to ensure that patients are reviewed, and anticipatory care plans are developed.
• Liaise with acute hospitals and coordinate the sharing of key information between the acute hospital teams and the MDT team.
• Act as a non-clinical contact for the care home to assist with case management of patients at risk of admission.
• Accurately read code and update/maintain patients' records for anticipatory care.
• Maintain an accurate record of two-week wait referrals for practice audits.
• Provide support with safeguarding admin (adults and child).

Workforce Responsibility:

The post holder must remain up to date with mandatory training as required. The post holder will be required to drive and may be required to undertake duties at any location in the community in order to meet service needs.

Concentration is required for data analysis, tracking patients and meetings, with frequent interruptions requiring attention and re-prioritisation of work.

Confidentiality: All employees are required to observe the strictest confidence with regard to any patient/client information that they may have access to, or accidentally gain knowledge of, in the course of their duties.

Data Protection: All employees must adhere to the Arbennek Healthcare Policy on the Protection and use of Personal Information.

Health and safety: Arbennek Healthcare expects all staff to have a commitment to promoting and maintaining a safe and healthy environment and be responsible for their own and others' welfare.

Other duties: The above job description is designed to give an overview of the tasks and responsibilities for this position; it is not intended to be exhaustive.

Person Specification:

• Qualified NVQ level 2 (or equivalent) Health and Social care.
• Minimum of 2 years experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field.
• Experience of administrative duties.
• Computer literate and proficient in the use of Microsoft packages and other software.
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
• Able to prioritise and manage own workload.
• Able to deal with service users sensitively.
• Able to work as part of a team.
• Strong analytical and judgement skills.
• Conscientious, hardworking and self-motivated to work with minimal supervision.
• Professional attitude and assertive approach.
• Committed to development both personally and for the organisation.
• Ability to meet deadlines and work under pressure.

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 to check for any previous criminal convictions.