Care Coordinator - University of Salford Health Centre (Salford South East PCN)

Care coordinators play an important role within the practice to proactively identify and work with certain patient cohorts to support in preparation for clinical conversations and to ensure the patients fully understand and are actively involved in managing their care.

At the University Health Centre you will be focused on supporting a wide variety of patients for example those patients seeking a diagnosis for ADHD and Autism, patients struggling with the transition to University, Transgender patients, patients suffering with anxiety, International students who need help in understanding the NHS system. As well as supporting the team on registration events across campus ensuring all students attending The University know how to access healthcare should they need it.

You will also work closely with a number of support networks across the University campus.

You would work closely with GPs and other professionals to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to fully understand the services and support available to them and to ensure their needs are met by discussing what matters to them. This is achieved by a personalised support & care plan.

You would review patient needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate. The role is an integral part of the multidisciplinary team. Adopting a holistic approach and listening to the patient's needs.

You will provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.,

• Work with patients, their families and carers to improve their understanding of treatment plans and the healthcare services available to them within primary care.


• Support the patient to develop and review personalised care and support plans to manage patient needs and achieve better healthcare outcomes.


• Help patients to manage their needs through answering queries, making and managing appointments, and ensuring that patients have good quality written or verbal information to help them make choices about their care.


• Assist patients to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.


• Support patients to take up training and employment, and to access appropriate benefits where eligible, for example, through referral to social prescribing link workers.


• Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.


• Work collaboratively with GPs and other primary care professionals within the PCN and local area to proactively identify and manage a specific cohort of patients, and where appropriate, refer to other health professionals within the PCN.


• Support the coordination and delivery of multidisciplinary teams with the PCN.


• Raise awareness of how to identify patients who may benefit from shared decision making and support staff and patients to be more prepared to have shared decision-making conversations.


• Explore and assist patients to access a personal health budget where appropriate.


• Follow the appropriate safeguarding procedures and ensure all safeguarding mandatory training is updated as and when required.


Key Tasks

Enable access to personalised care & support.

• Take referrals for individuals or proactively identify people who could benefit from support through care coordination.


• Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs.


• Work towards increasing patients' understanding of how to manage and develop health and wellbeing through offering advice and guidance.


• 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 to tailor support to them accordingly.


• Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register.


• Support people to develop and implement personalised care and support plans.


• 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, with activity recorded using the relevant SNOMED codes.


• Where a personal health budget is an option, to work with the person and the local CCG team to provide advice and support as appropriate.


Coordinate & Integrate Care

• Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.


• Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system.


• Refer onwards to social prescribing link workers and health and wellbeing coaches where required.


• 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.


• Actively participate in multidisciplinary team meetings in the PCN as and when appropriate.


• Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.


• Record what interventions are used to support people, and how people are developing on their health and care journey.


• Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.


• Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing.


• Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives.


• Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.


Professional development

• Work with a named clinical point of contact for advice and support.


• Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required.


• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
  
  The successful candidate will be caring, dedicated, reliable and person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people (and their families and carers) with high quality support.


Qualifications and training essential for post:

• Proficient in MS Office and web-based services


• Qualified via appropriate training (Personalised Care Institute) - This training will be completed at the start of your employment, Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way


• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity


• 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 it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role - e.g. when there is a mental health need 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 to promote collaborative practice with all colleagues


• Ability to 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


• Ability to work flexibly and enthusiastically within a team or on own initiative


• Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety


• Demonstrable commitment to professional and personal development is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute


• Proficient in MS Office and web -based services


• Experience of data collection and using tools to measure the impact of services


• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers


• Understanding of, and commitment to, equality, diversity and inclusion


• Strong organisational skills, including planning, prioritising, time management and record keeping


• Knowledge of how the NHS works, including primary care and PCNs


• Ability to recognise and work within limits of competence and seek advice when needed


• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence


• Basic knowledge of long -term conditions and the complexities involved: medical, physical, emotional and social


• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence


Desirable

• Ability to provide motivational coaching to support people's behaviour change


• NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards


• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)


• Experience of working within multi - professional team environments


• Experience of supporting people, their families and carers in a related role


• Experience or training in personalised care and support planning


• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation


• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement


• Knowledge of the personalised care approach


• Knowledge of Safeguarding Children and Vulnerable Adults policies and processes


• 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 locality on a regular basis


• Proficient speaker of another language to aid communication with people in the community for whom English is a second language