CLINICAL PRACTICE CARE COORDINATOR

NHS; Grantham; On-site; GBP 30,000 - 40,000; Full time

Job summary

A healthcare organization is seeking a Care Coordinator in Grantham to enhance support for patients at risk of hospitalization. The role focuses on proactive community engagement, enabling effective care and case management. Candidates should be registered health professionals with strong communication and organisational skills. This position offers a vital role within a supportive neighbourhood team aimed at improving patient outcomes and facilitating integrated care within the community.

Qualifications

• Ability to effectively organise own workload and that of others with minimum supervision.
• Experience of complex case management and multi-agency working.

Responsibilities

• Support the identification of people at risk of hospital admission.
• Liaise with healthcare professionals and provide comprehensive care to patients.
• Engage with patients in community and care home settings to assess needs.

Skills

Excellent communication skills

Organizational skills

Ability to work autonomously

Negotiation skills

Education

Registered Health or Care Professional

Postgraduate study in health-related studies

Tools

Microsoft Office

Job description

This post is offered to support existing Care Coordinator colleagues in St Peters Hill Surgery in Grantham to increase capacity to support people in their own homes and within care home settings.

The role will be employed within K2 Healthcare and based within the Grantham Neighbourhood Hub.

Main duties of the job

The role of the Practice Care Co-ordinator is to support boththe practice staff and members of the Neighbourhood Team to identify andsupport people to reduce the risk of unplanned hospital admissions and toeffectively support those individuals in the community.

To work dedicated hours to focus on proactively case managingpeople and being the preferred point of contact for the patient andNeighbourhood Team to achieve the following objectives:

To be a pro-active member of theIntegrated Neighbourhood Team and Southwest Primary Care Networks.

To pro-actively engage with peopledeemed to be at risk of hospital admission or health deterioration.

To proactively engage with frequentfliers those attending A&E and utilising OOH services.

To pro-actively engage with HomeFirst Teams to reduce length of stay in acute hospital settings.

To pro-actively engage with peopleliving in care home settings.

To be the key contact within the GPPractice environment.

About us

K2 Healthcare is a GP federation constituted of 16 member GP Practices in South West Lincolnshire with two Primary Care Networks and supporting a population of 133,000 people.

K2 works together to share resources and expertise that enable practices to provide shared services and business systems to provide the best possible care for our population, ensure sustainability, growth and value for GP practices and system partners within available resources.

The Better Lives Lincolnshire Integrated Care System sees us working in a provider collaborative with the Primary Care Network Alliance, Secondary Care, Community Health, Mental Health, Social Care as well as Local Authorities, and the Community and Voluntary Sector.

How we do it is as important as what we do and relationships with our partners is at the core of everything we do.

Neighbourhood Working describes an integrated approach to managing patients, through a blended workforce that encompasses both health and social care; to include acute, voluntary and community sectors where barriers to working are negated, the health and wellbeing needs of the individual are at the centre of decision-making, care is proactive and not reactive, and services are provided in a timely manner.

Job responsibilities

ROLE SUMMARY

Neighbourhood Working is a new way of strengthening andredesigning community services for a local population. It empowers people andcommunities to take an active role in their health and wellbeing, with greaterchoice and control over the care they need. It also supports the improvement,integration, and personalisation of services in Lincolnshire.

Core Neighbourhood Working Principles

Having a different conversation

Enabling self-care and peer support

Recognising whats important to me

Assessing immediate needs and addressing barriers toimprove quality of life

To liaise with the registered GP and other practice basedstaff in addition to all other providers and services utilising, whereappropriate, utilising a multi-disciplinary approach.

To implement and review individual care plans,self-management plans in liaison with the GP practice team. To include advancedcare plans, Respect documents, personalised care and support plans

Plan and monitor those on GP caseloads and directed by thepractice team or identified by the wider Neighbourhood Team at risk ofdeterioration.

Provide enhanced support to Nursing and Residential homeswith a focus on strengthening relationships and improving access throughinformation sharing, education, and advice.

To ensure all peoplein Nursing and Residential homes have care plans including advanced care plans,Respect documents, personalised care, and support plans and to provide aholistic review of all people in these homes with updates of their plans.

KEY RESPONSIBILITIES

Act as a point of contact between the GP Practice Team,Neighbourhood Team, people and their carers.

Develop and maintain a detailed knowledge of local servicesto enable supported signposting of people with identified need, sharinginformation with the Neighbourhood Team/Primary Care Network.

Liaise with GPs and practice teams to identify people who areelderly, frail or who have long term health need and support.

Support the early identification of those with life limitingconditions including those with palliative and end of life symptoms andconditions in order that they are supported to achieve a good end of lifeexperience.

Liaise with primary, secondary and specialist care servicesas required.

Work withNeighbourhood Team colleagues to help identify people at risk of loss ofindependence or admission to hospital as a result of inadequate social support.

Provide these cohorts of people signposting to identifiedservices to maintain their independence and improve their health andwell-being.

Visit people in community, home, or care home settings toassess and discuss their care needs involving carers as appropriate.

Implement personal care plans for individual people, ensuringpreventative actions are detailed to support the appropriate use of services.

Communicate the care plan to the GP and any other members ofthe Neighbourhood Team involved in the persons care and upload to the relevantrecords.

Ensure that identified people receive the right level of helpat the right time and help them to experience a joined-up service by liaisingwith relevant members of the Neighbourhood Team.

Work with patient, carers and the Neighbourhood Team toencourage the patient to adopt effective self-management and self-help seekingapproaches to reduce unnecessary hospital admissions.

Liaise with other agencies to ensure timely and appropriateengagement as required.

Support people to access community care assessments as wellas carers assessments.

Wherea personal healthcare budget is allocated provide advice as required regardingthe key choices the patient will need to make.

Identify unpaid carers and direct them to access services asappropriate to provide them with support.

Identify when urgent action or a step up in care is requiredand promptly alert the relevant member of the Neighbourhood Team, highlightingany safety concerns.

Follow up on communications from out of hospital andin-patient services regarding changes in condition of people to support thepractice to respond proactively to potentially unmet needs.

Undertake visits or telephone contact to manage people on thePCCs case load following any unplanned hospital admissions where appropriate.

Participate in Practice multi-disciplinary meetings todiscuss people actively being managed by the Neighbourhood Team and any otherpeople from the PCCs case load needing discussion.

To attend Neighbourhood Team MDT meetings plus any othermeetings. Updates between meetings to be shared with the Neighbourhood Teamcolleagues.

Maintain accurate and up to date records of patient contactsusing GP record systems and other IM&T systems relevant to the role i.e.entering notes onto SystmOne using agreed read codes.

To run regular patient searches using SystmOne to have anup-to-date record of progress of achievement of Key Performance Indicators inline with practice based recording and reporting requirements. Support thePractice Managers in providing KPI reports for submission as requested.

Work with K2Federation Southwest Primary Care Networks, Neighbourhood Team and other agenciesto support and further develop this role.

KEY WORKING RELATIONSHIPS

Practice teams

Neighbourhood Team

Care Homes

Communityhealth services

Mental Health and Learning Disability Services

Hospital teams including ward, A&E, discharge and AIRteams

Safeguarding agencies

Integrated Care Board

Adult Social Care

Social Prescribing Teams

Voluntary Services

Independent Care Homes

Local Authority teams

Housing Providers

Independent living teams

Person Specification

• Ability to effectively organise own workload and that of others with minimum supervision
• Ability to achieve goals with deadlines.
• Ability to work autonomously as well as within a team
• Ability to make decisions under pressure
• Ability to work sensitively to maintain high levels of diplomacy and confidentiality
• Enthusiasm, drive and the ability to cope in challenging situations
• Demonstrated capability to plan over short, medium and long-term timeframes and adjust plans and resource requirements accordingly
• Experience of setting up and implementing internal processes and procedures
• Ability to prepare and produce concise yet insightful communications for dissemination to senior stakeholders and a broad range of stakeholders as required
• Excellent communication skills, listening, written and verbal.
• Negotiation and conflict management skills and the ability to influence in formal settings
• Demonstrated capabilities to manage own

Qualifications

• Registered Health or Care Professional
• Post graduate study in health-related studies relevant to long term conditions or equivalent experience
• Evidence of continuing professional development
• Post registration teaching qualification or willingness to undertake

Skills and Knowledge

• Excellent communication skills, listening, written and verbal.
• Good organisational and planning skills.
• Excellent prioritisation skills and ability to work to tight deadlines.
• Skilled and sensitive communicator, confident in dealing with staff, people and service users
• Ability to deal with complex facts/situations, requiring analysis, interpretation and comparison of a range of options.
• IT skills including Good working knowledge and application of Microsoft Office packages
• Understand the wider determinants of health

Experience

• Experience of dealing with people with long term conditions.
• Evidence of ability to work autonomously.
• Evidence of working within a multidisciplinary team
• Evidence of teaching or mentorship
• Evidence of complex case management and multiagency working.

Disclosure and Barring Service Check

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.

Head of Integrated Neighbourhood Working