Care Co-Ordinator - Ormskirk Pcn

Job summary An exciting opportunity has arisen for a Care Co-ordinator to develop a pioneering role within primary care.
The role will provide co-ordination and navigation for people and their carers across health and care services.
This role mainly focusses on working as a part of our Enhanced Care Home SchemeCareCo-Ordinators provide extra time, capacity and expertise to support patientsin preparing for or in following up clinical conversations that they have withprimary care professionals doctors, nurses, physiotherapists, physicianassociates, paramedics etc.
They provide co-ordination and navigation forpeople and their carers across in a variety of settings, including care homeswhere they will work with the Enhanced Care Home Scheme Team to proactivelymanage this cohort of patients.The post holder will work closely with socialprescribing link workers, health and wellbeing coaches and other primary careroles.
Their focus is on delivering acomprehensive model for personalised care, reflecting local priorities, healthinequalities and population health management risk stratification.
They also support the coordination anddelivery of MDTs within PCNs.
Main duties of the job Therole is varied, and may include supporting self-management education, peersupport, case management and facilitating group consultations, as well as liaisingwith external stakeholders andprofessionals across Primary Care & Social Care, arranging, coordinatingand attending MDTs.Youwill take an approach that is non-judgmental, based on strong communication andnegotiation skills.
You will support personal choice and positive risk taking,while ensuring that patients understand the accountability of their own actionsand decisions.
Your role and skills will support and encourage the preventionof developing further illness, or the deterioration of existing long-termconditions.Whenworking with our local care homes, the role will focus on undertaking apersonal care and support plan for each resident and sign posting patient needsto fellow Enhanced Care Home Scheme Team members.
Ensuringseamless service provision significantly decreases the risk of the patientdeteriorating and thereby reduces the overall cost of care and the likelihoodthat additional interventions will be needed in future.
About us Employment will be with OWLS CIC Ltd West Lancashire GPFederation, as a central function to the GP Practices and Primary Care Network(PCN) members.OWLS CIC is a small GP owned and led not-for-profit primary careorganisation, run by GPs and health professionals.
OWLS was founded in the 90s by a small group of GeneralPractitioners, with the main aim of ensuring high quality out of hoursservices.
In 2017 it transitioned to become a GP Federation to support andprovide services for its practices and to offer a vehicle that local GPs had anopportunity to bid for, and provide, innovative primary care services in theirlocal area.
We are a not-for-profit organisation, which means that all themoney we generate through service contracts is invested back into providingpatient care.
Job description Job responsibilities Care Co-Ordinators will:Work closelywith practice and PCN healthcare roles, the PCC is to identify and work with acohort of people to support their personalised care requirements, using anyavailable decision support tools such as Patient Activation Measure (PAM),templates and softwareMeet patients, patientcarers and family members to discuss their personalised care requirements, theservices available to them and the help they wantVisit patients, checkingon the care that they have received and documenting it accordinglyWork with the care teamto evaluate interventions and identify where and when further ones will berequiredHelp peopleto manage their needs by answering their queries and supporting them in makingappointmentsSupportpeople to access appropriate benefits where eligible as well as taking upemployment and trainingAssistpatients to be better prepared to have conversations on shared decision makingand to improve awareness of shared decision making and related support toolsProvidepatients with high quality, easy to understand information to assist them inmaking choices about their careSupportpatients in understanding their level of knowledge, skills and confidence(known as activation level) when participating in their health and well-beingusing, where appropriate, the PAMLiaise withother PCCs in other practices across the region and share best practiceAssistpatients to access self-management education courses, peer support orinterventions that support them in their health and well-beingWhereappropriate, to assist patients to access personal health budgetsProvide coordinationand navigation of patients, and where appropriate their carers, across healthand social care services, where appropriate working hand in hand with socialprescribing link workers (SPLW)Support inthe delivery of enhanced services and other service requirements on behalf ofthe PCNLead in themanagement of patient complaints and participate in the identification of anynecessary learning brought about through clinical incidents and near-misseventsActively participate in the delivery of multi-disciplinaryteam (MDT) meetings within PCNs; responsible for preparatory admin, sendingmeeting invitations and taking notes of meetings.Undertake allmandatory training and induction programsContribute toand embrace the spectrum of clinical governanceContribute topublic health campaigns ( flu clinics) through advice or direct careLiaise with professionals across Primary Care& Social Care and co-ordinate the PCN MDT meetings.Collate all apatients identified care and support needs and review the options to meetthese needs and bring them into a single personalised care and support plan(PCSP) in line with best practicePromote CareCo-ordination, its role in self-management, addressing health inequalities andthe wider determinants of health.Raise awarenesswithin the PCN of shared decision making and decision support tools andsupporting people in shared decision-making conversations.Engage with andsupport the new and evolving agendas and service requirements across the PCN,including our work with Care Homes residents and the need to proactively managetheir care in an individualised way.Undertaking clinicalobservations to support the plans, as appropriate.Build relationships with staff in the GPpractices, attending relevant MDT meetings, giving information and feedback onhealth coaching.Provide education andspecialist expertise to fellow PCN staff, ensuring they are made aware of careco-ordination, health and well-being coaching and social prescribing servicesand support colleagues to improve their skills and understanding ofpersonalised care, behavioural approaches, and ensuring consistency in thefollow up of peoples goals where an MDT is involved.This job description and the above areas of responsibility are an indication of the role and could be subject to change.
Person Specification Qualifications Essential Minimum English GCSE grade C or equivalent Minimum Maths GCSE grade C or equivalent Desirable Customer Care Qualification Experience Essential Experience of working in a health care setting Skills and Knowledge Essential Computer literate with extensive experience of Microsoft Word, Outlook, Excel, PowerPoint and Access Excellent written, interpersonal and communication skills Ability to prioritise and have a flexible approach to workflows Strong focus on timely delivery of objectives and strong self-motivation Ability to communicate at all levels Active and empathetic listening Effective questioning Ability to build trust and rapport Professional behaviour at all times Effective time management Ability to work as a team member and autonomously Strong analytical thinking and ability to handle multiple tasks concurrently Ability to travel to locations across West Lancashire Experience of working in a Primary Care setting, healthcare environment and/or public sector is desirable Experience in working within a digital environment Planning and organisational skills Knowledge of the core concepts and principles of personalised care, shared decision making, patient activation, health behaviour change, self-efficacy, motivation and assets-based approaches Shared agenda setting/ collaborative goal setting/ shared follow-up planning Desirable Knowledge of personalised care Behaviours and Values Essential Strives for safe, quality, effective and efficient service provision Promotes open and honest dialogue, valuing individual differences, respect aspirations and commitments, and seeks to understand priorities, needs, abilities and limits Aware of the impact of own behaviour on others Leads by example and actively role models the NHS and L&SC TH Values in all work, fostering an inclusive culture with compassion and humanity Interprets equality, diversity and rights in accordance with legislation, policies, procedures and good practice Constructively challenges and accepts feedback from others Maintains confidentiality at all times