Health And Wellbeing Team Clinical Care Coordinator

Job summary An exciting opportunityhas arisen for an experienced HCA / Care Coordinator to join the award winning TWNSHealth and Wellbeing Team as an expansion to our hugely successful team.
Thismulti-disciplinary team is focused on proactive care and making a realdifference for the lives of our patient family across our PCN.
Focused onfrailty, dementia and patients with newly diagnosed cancer, the team have beenasked to showcase their work locally, regionally, nationally and internationally.
The TWNS Health andWellbeing Team, led by our highly experienced and talented Lead Nurse, iscomprised of two Health and Wellbeing Coaches and well supported by all ourpractices, the PCN Clinical Directors and our PCN Project Care Coordinator.
Theteam was first established in January 2022 and has evidenced significantbenefits for our patients and were thrilled to be able to expand furtherfollowing support from our local Gloucestershire Integrated Care System.
The team was createdspecifically by the TWNS PCN to recognise the needs of the local population andthe scope for transforming services to provide personalised care andwe'd love you to be part of this journey.
This is aclinical role and an integral part of the PCNs multidisciplinary team, workingunder the Lead Nurse and alongside our Health and Wellbeing Coaches, to providean all-encompassing approach to personalised care embeddingthe proactive and personalised care approach across the PCN.
Main duties of the job Please note this job will close early once sufficient applicants have been received.We're looking for anexperienced HCA or Care Coordinator to support the team across all aspects ofthe teams work, undertaking functions such as: Regular and frequentface-to-face and telephone conversations completing assessments withpatients, under the direction of the Lead Nurse: Utilising and establishingsystems to coordinate patient access to services; Enabling smooth andplanned transfer between care settings; Providing advice,information and signposting to services; Oversee safeguardingadministration and communication with partner organisations where required; Ensuring personalisedhealth and care planning is proactive, supportive and patient-centred.Successful candidates willbe adept at SystmOne, able to vaccinate and take bloods, are caring, dedicated,reliable and person-focussed and enjoy working with a wide range of people.They will have good written and verbal communication skills and strongorganisational and time management skills.They will be highly motivated andproactive with a flexible attitude, keen to work and learn as part of a teamand committed to providing people, their families and carers with high qualitysupport.The HCA or Care Coordinatorwill have a key role in a small, but dynamic and vibrant, team, supportingdelivery of excellent proactive care.
About us TWNS PCN supports over 50,000patients registered at one of our five practices: Church Street, Mythe Medical,Newent, Staunton & Corse and West Cheltenham Medical.
The team are embedded atthe heart of our five practices, building longstanding relationships with thelocal diverse community and provide lifelong care across this broadgeographical community.
The TWNS PCN team iscommitted to understanding and responding proactively to the needs of the mostvulnerable patients, supporting them to enjoy good health and independence andfor as long as possible.
Come and work with us andbe part of this innovative, award-winning and dynamic team, working inpartnership with patients and enabling excellent care.
Job description Job responsibilities This Care Coordinator positionis a critical post in the continued success of the award winning TWNS PCNsHealth and Wellbeing Team.
The team are embedded at the heart of our fivepractices, building longstanding relationships with our local diverse communityand provide lifelong care across this broad geographical community.
The teamare committed to understanding and responding proactively to the needs of our mostvulnerable patients, supporting them to enjoy good health and independence andfor as long as possible.This clinical role is anintegral part of the PCNs multidisciplinary team, working under the Lead Nurseand alongside our Health and Wellbeing Coaches, to provide an all-encompassingapproach to personalised care; promoting and embedding the proactivepersonalised care approach across the PCN.
The role provides acentral coordination function for patient care planning: undertaking both face-to-face and telephoneappointments with patients, performing routine clinical tasks such asphlebotomy, BP monitoring, and supporting some of our associated patientgroups, as required.
In addition, the role oversees safeguardingadministration, document handling, record management and communication withpartner organisations across health and social care.Main Responsibilities1.
Facilitate and ensurethe effective delivery of proactive, patient-centred, personalised care for identifiedcohorts of patients across the breadth of the work of the Health and WellbeingTeam, inclusive of frailty, dementia and cancer.
This will involve monitoringprogress and reporting outcomes, contributing to patient reviews and careplanning within appropriate timeframes.2.
Explain the managementof a patients pathway, liaising between services and service users, contactingservices using the appropriate procedures/referral mechanisms.3.
Work closely with allrelevant care agencies (primary care, secondary care, community services, voluntaryservices and other relevant service providers) to ensure coordinated deliveryof the patients care plan, without requiring a further referral from the GP.4.
Maintain accuraterecords and statistical returns as determined by the Lead Nurse, includingproviding patient-related information for entering into SystmOne, within therequired timeframe.5.
Adhere to infectionprevention control policies 6.
Collect data onpatients/carers for recognised outcome measure and document for serviceinterpretation.
Ensure all patient notes are updated to reflect any changes,including details on plans.7.
Organise and attendrelevant meetings when required including supervision, PCN meetings,multi-disciplinary team meetings etc, ensuring that any necessary documentationis circulated in advance.8.
Contribute to auditsand data collection to aid evaluations of the PCN services will be needed.9.
Advise patients ondiet, lifestyle as well as physical and mental wellbeing, along withsignposting to local services and funding they may be eligible to access.10.
Be a contact pointfor the TWNS PCNs practices and establish systems and processes which willensure a timely and appropriate response to queries from clinicians and otherstakeholders.
Person Specification Qualifications Essential Qualifications and training GCSE English and Mathematics (or equivalent level) Qualifications and training Enrolled in (or willing to), undertaking or qualified from appropriate training for Care Coordinators, as set out by the Personalised Care Institute Clinical skills and qualification at HCA level (minimum level 2) or able to demonstrate experience to equivalent level.
Demonstrable commitment to professional and personal development Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way Commitment to reducing health inequalities and proactively working to reach people from diverse communities Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders Ability to identify risk and assess / manage risk when working with individuals Have a strong awareness and understanding of when to refer people to other health professionals/agencies when beyond the scope of the care coordinator role mental health needs requiring a qualified practitioner Ability to work from an asset-based approach, building on existing community and personal assets Ability to maintain effective working relationships and promote collaborative practice with all colleagues, demonstrate personal accountability, emotional resilience and work well under pressure Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines High level of written and verbal communication skills Knowledge of, and ability to work to policies and procedures, including: confidentiality, safeguarding, lone working, data security, health and safety Ability to work flexibly and enthusiastically within a team or on own initiative Desirable Experience or training in personalised care and support planning Experience of data collection and using tools to measure the impact of services Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Knowledge of the personalised care approach Experience Essential Experience of working directly in a care coordinator or HCA role, using SystmOne, in primary or community care setting Experience of working within multi-professional team environments Desirable Experience or training in personalised care and support planning Experience of data collection and using tools to measure the impact of services Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Other Essential Information Essential Meets DBS reference standards and criminal record checks Willingness to work flexible hours when required to meet work demands Access to own transport Ability to travel across the PCN as required Commitment to reducing health inequalities and proactively working to reach people from diverse communities Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders Ability to identify risk and assess / manage risk when working with individuals