Care Co-ordinatorNHS

Job summary

We are seeking a compassionate, proactive and organised Care Co-ordinator (Care Homes) to join our Enhanced Care Team on a part-time basis.

Care Co-ordinators play a vital role in supporting patients with complex and long-term care needs. Working within a dedicated Enhanced Care Team, they specialise in one or more key service areas including frailty, care homes, learning disabilities, cancer/palliative care and serious mental illness.

We are looking for someone who:

• Has excellent interpersonal and communication skills, with the ability to build rapport and trust with a wide range of people
• Is highly organised and able to manage a varied workload effectively
• Demonstrates empathy, compassion, and a person-centred approach to care
• Can work confidently and professionally within a busy and sometimes challenging environment
• Has the ability to establish and maintain effective working relationships with external partners and healthcare professionals
• Is committed to delivering high-quality support that improves patient experience and outcomes

This is a part-time position, and we welcome applications from candidates seeking 28 to 30 hours per week, working Monday to Friday with a working pattern to be agreed.

Please note: We reserve the right to close this vacancy early should we receive a high volume of applications.

Vine Medical Group is committed to equality, diversity, and inclusion. We actively encourage applications from veterans, service leavers.

Main duties of the job

The Care Co-ordinator (Care Homes) will work closely with the Clinical Team to support patient care and the delivery of timely, appropriate and well-co-ordinated enhanced care services to care home residents. You will also maintain an awareness of the wider patient cohorts supported by the Enhanced Care Team, contributing to effective multidisciplinary working, service continuity, and the sharing of best practice across the team.

You will proactively manage a caseload of patients with complex care needs, ensuring coordinated, person-centred support and timely review of changing health and wellbeing needs.

You will act as a key link between the Practice and our local care homes, coordinating care plans, medication and health reviews, supporting weekly care home ward rounds, registration of new residents and supporting clinicians. You will build relationships and work closely with patients, carers, care home staff, GPs, community services, and partner organisations. Ultimately helping us to deliver high-quality, integrated care that improves patient outcomes and experience.

You will support the development and review of personalised care plans, facilitating access to health and care services, promoting effective communication across healthcare providers.

Job description

• Support the Clinical team to deliver enhanced care services to the key service area of Care Homes and other differing patient cohorts as required. Maintaining an awareness of other cohorts supported by the Enhanced Care Team to enable effective team work and sharing of good practice.
• Identify and manage a caseload of identified patients, making sure that appropriate support is made available to them, and ensuring that their changing needs are addressed
• Bring together all the information about a persons identified care and support needs and explore options to meet these within a single personalised care and support plan
• Help create single personalised care and support plans, in line with best practice
• Assist and direct patients in accessing the appropriate service or healthcare professional in a courteous, efficient and effective way
• Facilitate effective communication between patients, members of the primary health care team, secondary care and other associated healthcare agencies
• Support a formalised process of delivering healthcare reviews to patients
• Support the Clinical Directors and team to deliver the Directed Enhanced Services specifications for individual services
• Co-ordinate the work of healthcare professional and non-clinical staff including volunteers and keep an up-to-date database of contacts
• Build and develop relationships with partner organisations, such as community services, volunteer groups, community learning disability teams, care homes and keep a comprehensive and up to date database of contacts
• Provide a link between Vine Medical Group and Homewell Practice
• Provide advice and information ensuring health and care planning is timely, efficient and patient-centred
• Ensure that all relevant and useful information is available to patients/clinicians and is up to date
• Support teams with quality improvement projects and achieving KPIs (QOF and IIF)
• Monitor and cleanse existing data. Ensure data is recorded and coded accurately and aligned with the PCN
• Understand and provide support for digital initiatives
• Attend regular / monthly meetings to discuss good practice and share information
• Keep records of your work and adhere to confidentiality, information sharing protocols and provide monitoring information as required
• Undertake regular training to extend and update own knowledge of health and wellbeing issues
• Alert Team Lead or Senior Management of any issues that may impact patient safety or service quality
• Be familiar with patient safety policy and reporting (e.g. LFPSE and/or other appropriate systems) and awareness of the process and key stakeholders for safeguarding referrals
• Maintain accurate patient / clinical records in conjunction with Practice policies and current legislation
• Ensure adherence to confidentiality, data protection, and information governance requirements
• Work safely at all times in accordance with legislative requirements and Practice Policy and Procedures

Care Home Support:

• Undertake weekly calls and scheduled visits to local care homes to support GP-led ward rounds to ensure support and access and coordinate clinical unput where required. Regular travel across the locality is an essential requirement of the role
• Register new care home patients and manage proxy access, liaising with the Admin team and care home managers as required
• Co-ordinate regular Multi-disciplinary Team meetings. Take notes and record actions at these meetings
• Manage the Practices care home email inboxes and ensure that all emails and documents are dealt with or distributed to the appropriate clinician
• Keep up to date contact information and processes for all care homes
• Ensure that all relevant and useful information is available to the care homes and is up to date
• Develop relationships with external third parties that help support care homes and their residents
• Ensure that all relevant information or changes from external stakeholders, such as Care Home Managers, CCG, NHS England is shared with the Care Home Team
• Maintain patient appointment lists for ward rounds

About us

Vine Medical Group is one of the largest practices in the locality. We care for around 25,500 patients across the whole of the Waterlooville area and its surrounding villages. We are one of two practices in Strawberry Health Primary Care Network with shared responsibilities for approximately 41,000 patients.This larger size means more diverse learning and development opportunities are possible to aid with longer term career development goals. We are a family-friendly practice and try to accommodate working patterns to suit as far as we can.

We operate across four locations; the Forest End, Waterlooville Health Centre, Aintree Drive and Stakes Lodge sites. We employ a multi-skilled team including GPs, Practice Nurses, Advanced Nurse Practitioners, Healthcare Assistants, Paramedics, Pharmacists and skilled administrative teams who support the smooth running of the Practice.

Our Enhanced Care Team includes Social Prescribers, Care Co-ordinators, Wellbeing Advisors and Mental Health Practitioners. The team proactively supports our patients health and wellbeing providing a personalised care approach.

We are rated Good by the CQC.