Address
Form of workJob summary
North Care Network
We are looking to recruit a Care Coordinatorswith a focus on cardiovascular disease to join our growing multi-disciplinary team (the role would particularly suit a Health Care Assistant Band 3-4 dependent on skill set and potential for additional training).
This exciting role will work as part of a wide team to help identify and reduce health inequalities in CVD related illness for our patients and improve health and wellbeing outcomes.
The successful candidates will take a hands on approach to identifying and managing patients with risk factors for cardiovascular disease and to managing patients with established cardiovascular disease.
Main duties of the job
Main Duties include:
Coordinate and perform all aspects of the NHS Health check on suitable patients including blood pressure checks, taking blood and making risk factor enquiries. Provide advice and signposting for support and treatment based on the findings.
Counsel patients on their risk factors for cardiovascular disease and how to modify them.
Coordinate the loan and return of home blood pressure monitors and ambulatory blood pressure monitors, guiding patients on their use and follow up care.
Identify patients who have not received or accepted follow up care for their conditions, making contact with them and supporting them to access care.
Provide coordination and support for people and their carers across health and care services, closely working alongside social prescribing link workers and other primary care roles.
Liaise with allied services such as NHS stop smoking services and weight management services ensuring timely and appropriate referral.
Coordinate and deliver health assessments such as BP checks, height and weight measurement, urine dip tests and ECGs documenting results on the clinical system.
Running evening drop-in sessions for patients to have blood pressure checks and weight monitoring as well as receiving support to modify their reversible cardiovascular risk factors.
Maintain accurate and up to date clinical records.
About us
North Care Network (NCN ) is a forward thinking Primary Care Network based in North Lincolnshire, with a registered patient population of approximately 33,859 across the 3 member practices. Our multidisciplinary teams are committed to reducing health inequalities and improving health and wellbeing outcomes by providing high quality care coordinated care, with a focus on prevention, early identification, and improved management of existing disease/illness.
Our member practices are Central Surgery (Barton upon Humber), Winterton Medical Practice (Winterton) and Bridge Street Surgery (Brigg).
Job description
Job responsibilities
As a Care Coordinator you will play an important role within NCN to proactively identify and manage people identified as living with, or at risk of developing diseases. There will be a particular focus during the first year of employment on cardiovascular conditions such as high blood pressure, high cholesterol, diabetes, coronary heart disease and strokes. A key part of the role includes undertaking health assessments and identifying and coordinating appropriate referral routes to improve patient outcomes through coordinated access to support and advice across health, care and local voluntary and community services.
You will work closely with practice teams to support patients and carers to understand and manage their conditions and ensuring their changing needs are addressed in a holistic manner.
The successful candidate will be based within the practices of North Care Network but mainly at our Bridge Street Practice. They will be caring, dedicated, reliable and enjoy working with a wide range of people. They will have excellent written and verbal communication skills and strong organizational and time management skills. They will be highly motivated and proactive with a flexible attitude and be keen to work and learn as part of a team committed to providing people, their families, and carers with high quality support.
As well as providing care coordination the role will involve hands on patient care such as blood pressure checking, phlebotomy, ECG taking and INR measurement.
Key responsibilities
Undertake NHS health checks and record findings in clinical systems, working to necessary protocols and policies, assessment of risk, communication of results and onward referral.
Deliver drop-in sessions for patients to have height and weight checks along with support and signposting to allied services
Work with people, their families, and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Coordination of ambulatory and home BP monitoring services. This will include identifying patients, loaning of the equipment with delivery of appropriate patient training, adding results to patient records, organising follow up onward referrals as appropriate according to protocols.
Help people to manage their needs through answering queries, making, and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
Support people to understand their level of knowledge, skills, and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure (PAM).
Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their Activation level.
Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, 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 to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer to other health professionals within the PCN.
Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.
Work with people, their families, carers, and healthcare team members to encourage effective self-management of health conditions (when appropriate)
Maintain records of referrals and interventions to enable monitoring and evaluation of the service
Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances
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.
Professional development
Work with a named clinical point of contact for advice and support.
Undertake continual personal and professional development
Adhere to organizational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety
Establish strong working relationships with GPs and practice teams and work collaboratively with other Care Coordinators, social prescribing link workers
Job description
Job responsibilities
As a Care Coordinator you will play an important role within NCN to proactively identify and manage people identified as living with, or at risk of developing diseases. There will be a particular focus during the first year of employment on cardiovascular conditions such as high blood pressure, high cholesterol, diabetes, coronary heart disease and strokes. A key part of the role includes undertaking health assessments and identifying and coordinating appropriate referral routes to improve patient outcomes through coordinated access to support and advice across health, care and local voluntary and community services.
You will work closely with practice teams to support patients and carers to understand and manage their conditions and ensuring their changing needs are addressed in a holistic manner.
The successful candidate will be based within the practices of North Care Network but mainly at our Bridge Street Practice. They will be caring, dedicated, reliable and enjoy working with a wide range of people. They will have excellent written and verbal communication skills and strong organizational and time management skills. They will be highly motivated and proactive with a flexible attitude and be keen to work and learn as part of a team committed to providing people, their families, and carers with high quality support.
As well as providing care coordination the role will involve hands on patient care such as blood pressure checking, phlebotomy, ECG taking and INR measurement.
Key responsibilities
Undertake NHS health checks and record findings in clinical systems, working to necessary protocols and policies, assessment of risk, communication of results and onward referral.
Deliver drop-in sessions for patients to have height and weight checks along with support and signposting to allied services
Work with people, their families, and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Coordination of ambulatory and home BP monitoring services. This will include identifying patients, loaning of the equipment with delivery of appropriate patient training, adding results to patient records, organising follow up onward referrals as appropriate according to protocols.
Help people to manage their needs through answering queries, making, and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
Support people to understand their level of knowledge, skills, and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure (PAM).
Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their Activation level.
Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, 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 to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer to other health professionals within the PCN.
Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.
Work with people, their families, carers, and healthcare team members to encourage effective self-management of health conditions (when appropriate)
Maintain records of referrals and interventions to enable monitoring and evaluation of the service
Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances
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.
Professional development
Work with a named clinical point of contact for advice and support.
Undertake continual personal and professional development
Adhere to organizational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety
Establish strong working relationships with GPs and practice teams and work collaboratively with other Care Coordinators, social prescribing link workers
Person Specification
Experience
Essential
- Experience as a healthcare assistant, Care Coordinator, phlebotomist, or nurse
- Grades C or above in Maths and English at GCSE level.
- Good computer skills are essential - able to use Microsoft Office and Excel.
- Experience of dealing with vulnerable people.
- Experience of working in health and social care settings and other support roles in direct contact with people, families, and carers.
- Experience of working within multi professional team environments.
- Ability to prioritise their own workload to meet strict deadlines.
- Has attention to detail, able to work accurately, identifying errors quickly and easily.
- Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience.
- An excellent understanding of data protection and confidentiality issues.
- Ability to listen and empathise with people holistically identifying their needs and supporting them to address them.
- Can work effectively independently and as a team member
- Ability to communicate effectively both verbally and in writing
- Able 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
Desirable
- Desirable
- Working knowledge of S1/EMIS clinical systems.
- Ability to provide motivational coaching to support people's behaviour change
- Qualifications such as NVQ level 3 HCA, The Care Certificate, Diploma in Healthcare Support and Personalised Care Institute qualification.
Person Specification
Experience
Essential
- Experience as a healthcare assistant, Care Coordinator, phlebotomist, or nurse
- Grades C or above in Maths and English at GCSE level.
- Good computer skills are essential - able to use Microsoft Office and Excel.
- Experience of dealing with vulnerable people.
- Experience of working in health and social care settings and other support roles in direct contact with people, families, and carers.
- Experience of working within multi professional team environments.
- Ability to prioritise their own workload to meet strict deadlines.
- Has attention to detail, able to work accurately, identifying errors quickly and easily.
- Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience.
- An excellent understanding of data protection and confidentiality issues.
- Ability to listen and empathise with people holistically identifying their needs and supporting them to address them.
- Can work effectively independently and as a team member
- Ability to communicate effectively both verbally and in writing
- Able 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
Desirable
- Desirable
- Working knowledge of S1/EMIS clinical systems.
- Ability to provide motivational coaching to support people's behaviour change
- Qualifications such as NVQ level 3 HCA, The Care Certificate, Diploma in Healthcare Support and Personalised Care Institute qualification.
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.
Employer details
Employer name
The Central Surgery
Address
Bridge Street Surgery
53 Bridge Street
Brigg
DN20 8NT
Employer's website
https://www.centralsurgery-barton.co.uk/ (Opens in a new tab)
