Care Coordinator Lead

Job summary

We are recruiting for a Care Coordinator Lead to join North Sedgemoor PCN. This is a permanent role. The successful candidate will work across our practices and as part of a multi-disciplinary team.

A Primary Care Network (PCN) Care Coordinator Lead is responsible for the leadership of the Care Coordinator Team within North Sedgemoor PCN whilst also leading on PCN projects.

This is a role for someone who enjoys autonomy, professional responsibility and variety. You will join an established leadership team, with opportunities for further development and leadership.

Main duties of the job

• Act as Team Leader for Care Coordinators and support other teams by working with the PCN as a whole and individual practices to identify and address access barriers to facilitate improvements in patient access to services.
• Provide oversight, supervision and governance to, and to take accountability for, the performance of the Care Coordinator Team to ensure compliance with best practice and the requirements of the Network Specification.
• Care Coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across healthcare services.
• They work closely with GPs and practice teams 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 understand and manage their condition and ensuring their changing needs are addressed.
• Care Coordinators review patients needs and help them access the services and support they require to understand and manage their own health and well-being, referring to social prescribing link workers, health and well-being coaches, and other professionals where appropriate.

About us

North Sedgemoor PCN is a collaboration of five GP practices caring for around 50,000 across Burnham on Sea, Berrow, Highbridge, Cheddar, Brent and Axbridge. We are clinically led and community focused, with a strong track record of working together to improve services for our population.

You will be joining an experienced leadership team led by the PCN Manager and our Clinical Directors.

We offer a supportive, professional environment where you will be able to develop your skills further, share learning with colleagues, and play a key role in shaping the future of the PCN. You will also benefit from NHS pension, generous annual leave, well-being resources and the opportunity to work in a team where your contribution is recognised and valued.

Job responsibilities

Care Coordinator Team Leader Key Responsibilities

• To work with and support the PCNs Clinical Director, PCN Manager, Operational Lead, other PCN Leads and their teams to ensure effective delivery of the PCN DES and IIF requirements.
• Responsible for assisting with day-to-day operational delivery within the Care Coordinator team.
• To undertake day-to-day line management of all Care Coordinators across the PCN.
• When staff absences occur, ensure service is maintained and delivered.
• Trouble shoot day to day and respond to any queries from the Care Coordinator and wider team as required.
• Develop and maintain effective communication between the Care Coordinator team and with both the ARRS staff and all partner practices.
• Provide support to the Operational Lead regarding project implementation and communications for new services.
• Help develop joint working and relationships across the network and its stakeholders.
• Communicate information and issues within the Care Coordinator Team, including cascades and reports.
• Maintain excellent relationships across all core member Practices.
• To arrange monthly and adhoc Care Coordinator Team Meetings. Compiling agendas, leading the meetings, and taking minutes for circulation across the Care Coordinator team.
• Supporting the other PCN teams with additional work stream and day-to-day operational administration requests.
• Work closely with the Operational Lead to evaluate Care Coordinator activity within PCN services to drive further improvements.
• Help the senior leadership team to develop policies and procedures that are accurate in relation to Care Coordinator processes.
• To develop and maintain the Care Coordinator TeamNet communications page and the active Microsoft Teams channels in relation to Care Coordinator activity.
• Work with the PCN member practices to identify and address access barriers for those who struggle to access healthcare.
• Working with other PCN Health Coaches and Care Coordinators, raise awareness of health promotion, screening, NHS Health Checks and LD Health checks with patients.
• Work flexibly, adapting to the needs of the service and client group while maintaining the integrity of the role.
• Escalate well-being, performance and sickness staff concerns to the senior leadership team for them to safeguard well-being and initiate sickness support plans and performance management reviews. Support senior leadership with Care Coordinator appraisals. Work with the senior leadership team to retain staff and develop the Care Coordinator workforce.
• Provide line management to the Care Coordinators; including the management of the absence line, the addition of absences to TeamNet along with reasons for absence, completion of return-to-work interviews, the managing of and arranging cover for Care Coordinator staff as required.
• Support the senior leadership team with the recruitment of new Care Coordinator staff, from advert to appointment, as required and attend interviews, actively being part of the recruitment scoring process.
• Support the senior leadership team with the arrangement and completion of Care Coordinator staff onboarding, consisting of inductions and training.
• Act as a role model for the delivery of the high standard of patient care and lead the Care Coordinators towards this shared goal. Work collaboratively with the PCN staff members and stakeholders to meet the needs of patients.

Care Coordinator Key Responsibilities

Patient Identification - Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care

• Liaise with external providers and collate information for presentation at MDT meetings.
• Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the daily One Team MDT meetings.
• Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the appropriate MDT.
• Signpost team members, service users and carers to relevant services.

Direct Patient Facing Work

• Support with the administration and overall patient journey of the Community Investigation Hub. Providing additional clinical services for the PCN footprint, based at Burnham Community Hospital.
• Manage a caseload of patients identified through the MDT or practice.
• Support patients to utilise decision aids in preparation for a shared decision-making conversation.
• Holistically bring together all a patients identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the patient.
• 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.
• Support patients to take up training and employment, and to access appropriate benefits where eligible.
• Support patients to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and well-being, including through the use of the Patient Activation Measure.
• Assist patient to access self-management education courses, peer support or interventions that support them in their health and well-being and increase their activation level.
• Explore and assist patients to access personal health budgets where appropriate.
• Refer or liaise with the Health Coaches and Village Agents as appropriate.

Communication and collaborative working relationships

• Overall responsibility for arranging the daily PCN led One Team MDT meetings and the smooth running of integrated care within the team setting. A key role of the Care Coordinator is to ensure that all new referrals are identified, and information circulated to team members in advance of the meeting.
• Take notes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
• Demonstrate the ability to work as a member of a team.
• Demonstrate the ability to recognise own personal limitations and refer to more appropriate colleague(s) when necessary.
• Actively work towards developing and maintaining effective working relationships both within and outside the PCN.
• Liaise with other stakeholders as needed for the collective benefit of patients including but not limited to patient GPs, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations.
• Work with service users, PCN practices and partners e.g., Care Homes to ensure new referrals are logged and allocated.
• Develop excellent working relationships with all partners, wider service networks including the voluntary sector, GP practices, adult social care, care homes, hospitals, community pharmacists and other members of the MDT.
• Meet regularly with the clinical lead and review case load and MDT function.
• Keep the MDT and other external providers updated with positive news stories via a circulated newsletter.

Safeguarding

The post-holder to be aware of all current safeguarding policies which are available on our TeamNet portal.

Equality and diversity

• The post-holder will support the equality, diversity and rights of patients, carers and colleagues by:
• Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation.
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
• Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

Other responsibilities

• To act at all times in an anti-discriminatory manner.
• To be able to plan and respond to workload according to operational priorities.
• To support the delivery of these functions across wider locality areas where necessary.
• To undertake any training required to maintain competency including mandatory training.
• To contribute to, and work within a safe working environment.
• Identify and raise any clinical incidents to the senior leadership team and participate as required in any investigation and learning exercise.
• The Care Coordinator Lead must adhere to the PCNs policies and procedures.
• The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.

This job description may be reviewed in the light of changing organisational and service needs. Any changes will be fully discussed with the post-holder. The post holder may also be required to carry out other work appropriate to the grade of the post.

Person specification

Qualifications

Desirable

• Coaching or counselling qualification or relevant experience.
• Leadership qualification.

Experience

Essential

• Experience of working in Primary Care
• Experience of using clinical software, eg. EMIS
• Experience of working in a multidisciplinary team.
• Excellent group and one-to-one facilitation skills including conflict resolution.
• Skilled in active and reflective listening.
• Good people management skills.
• Ability to work with minimal supervision and act decisively and ask for help when needed.
• Excellent communication and presentation skills.
• Proficient on Office 365.
• Ability to travel across multiple sites.

Desirable

• Experience in managing or leading a team.
• Networking experience.
• Experience of successful partnership working across statutory, voluntary and community sector.