Care Coordinator; THG PCN

Underthe direction of the PCN team, a care coordinator will be required to undertake the following and will receive the relevant training and supervision to:

identifya cohort of patients who meet specific criteria as determined by the Service priority areas using population health intelligence;

Deliver personalised holistic healthcare and support in order to manage their needs proactively, exploring options or a single personalised care and support plan.

Provide advice, guidance and signpost to other services, co-ordinate patient care services and work with the care team to evaluate interventions

Thecore competencies required of a Care Co-ordinator are as follows and the specific duties and responsibilities are identified below.

The Care Coordinator will work as part of the PCN team to provide personalised, holistic support to patients, helping them to access appropriate care, services and support. Key duties will include:

Using population health intelligence to identify and proactively support cohorts of patients in line with service priorities and contractual requirements. Contacting patients to understand their individual needs, supporting shared decision-making and developing trusting, person-centred relationships. Supporting patients to manage their health and wellbeing by providing information, answering queries, coordinating appointments and helping them understand their care options.

Developing and supporting personalised care and support plans with patients and their families, ensuring records are accurate and kept up to date.

Navigating and signposting patients, carers and families to appropriate health, social care, community and voluntary sector services, working closely with social prescribing and other PCN roles.

Monitoring patient progress and recognising when additional or urgent support is required, escalating concerns appropriately to relevant professionals. Supporting access to self-management education, peer support, training, benefits and other interventions that promote health and wellbeing.

Supporting MDT meetings, including those relating to care homes, and assisting with vaccination programmes where required.

Trinity Health Group is a PCN made up of four practices on the west of the district (Trinity Medical Centre, Maybush Medical Centre, Crofton and Sharlston Medical Practice and Warrengate Medical Centre). Our vision is that all our patients should have the same chance at a happy, healthy life. We believe that a sustainable, resilient Primary Care Service working collaboratively with volunteer and community services and social enterprise organisations supports this vision.

Our Mission is to add years to the lives of our patients and to add life to those years.

For the full Job Description and Person Specification for this role, please see the additional documents attached.

• Educated to NVQ level 3 in a relevant subject or equivalent qualification or proven relevant experience.
• Experience of working in a support role either in the health and social care sector or within a customer focused based organisation.
• Evidence of undertaking the relevant care coordinator training and/or the care certificate.

• Recognises when the limits of own competence are exceeded and is able to identify how and from whom to seek support.
• Listens proactively and collaborates with colleagues and wider teams and is able to share learning from their experiences
• Acts with integrity and professionalism at all times and is conscientious and committed to provide a high-quality service.

• Is able to demonstrate evidence that the role holder is able to meet the core competencies outlined in the above description.
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