Care Home Coordinator

Purpose

As a Care Homes Care Co-Ordinator, you will be responsible for helping to improve the continuity of care by acting as a point of contact for residents, families and professionals who visit, or work in the Care Home, such as multi-disciplinary team (MDT) members and in-reach specialists. You will work to provide extra time, capacity and expertise to support individuals’ in preparing for, or in following- up clinical conversations they have with primary care professionals. You will work closely with primary care professionals within the PCN to identify and manage a caseload of identified Care Homes; making sure that appropriate support is made available to the staff and their residents; and ensuring that their changing needs are addressed. You will focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health.

Main Responsibilities

• Proactively identify and work with a group of Care Homes to support personalised care requirements for their residents, using the available decision support aids.
• Help people to manage their needs, answering their queries and supporting them to make referrals into the Care Home MDT or escalation of need to the Care Home Clinical Team.
• Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision-making conversation.
• Ensure that people have good quality 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 use of the Patient Activation Measure.
• Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
• Explore and assist people to access personal health budgets where appropriate.
• Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
• Lead the coordination and delivery of the Care Home MDTs within the PCN.
• Liaise and work with multiple services and external stakeholders, acting as a conduit for information sharing and communication between the CCG, GPs, practices, KCHFT, Social Care Teams, KCC Commissioners, patients, and voluntary sector.
• Have a sound knowledge of health and social care policy, together with local services and health promotion initiatives, that will enable the safe transfer of clients between different provider services, and the integration of services from different providers where indicated.
• Support the continued development and coordination of an Integrated Health and Social Care MDT meetings approach across the Primary Care Network. This will provide a coordinated response to referrals from GPs and health and social care teams.
• Ensure that patients are signposted to the correct health, social or voluntary agency in a timely manner.
• Develop an understanding and awareness of all the resources available, both public and independent to meet the needs of people in the community.
• Identify and process any safeguarding and quality of care issues and refer onwards to ensure that clients’ welfare is protected as per agreed protocols.
• Work to actively identify service development initiatives.

Communication and Relationships

• Provide a single point of contact for GPs and the PCN to support them with investigating service user/patient case history to improve coordination of care.
• Coordinate and attend Inter-professional meetings, providing appropriate feedback.
• Record, minute and monitor outcomes and actions from the MDTs as required within each PCN.
• Implement and follow up key action points from the MDT meetings on to the agreed care plan which is clear and concise contemporaneous.
• Effectively communicate a patients’ needs within a multidisciplinary team meeting environment.
• Take Health and Social Care referral information according to required process e.g. via SBAR which may involve carrying out telephone or face to face contact (if NVQ trusted assessor if not to access training) assessments and receiving referrals from other agencies and professionals on a daily basis. Ensuring accuracy and demonstrating non-judgmental and objective work practice and consideration of service users and carers views.
• Develop and maintain effective working relationships with integrated teams including long term and practice linked teams, GP practices and other agencies to ensure that service users receive a consistent, integrated response to all contacts/referrals.
• Work with the PCN team and others in determining the most appropriate response to individual clients in a crisis situation and in arranging and coordinating that response within the wider PCN MDT.
• Analyse the information provided and determine which service best meets the need of the patient.
• Determine the patients’ holistic support needs accurately over the telephone or face-to-face.

Infection Control

• Follow procedures aimed at reducing the risk of passing on the organisms that can cause infections.
• Follow best practice in adherence to guidelines which is a fundamental requirement in underpinning the management of Infection, Prevention and Control.
• Apply infection control measures within the practice according to oval and national guidelines. This includes: Dealing with blood and body fluid spillages, Decontamination of instruments and clinical equipment, Reporting and treatment of sharps injuries, Segregation and disposal of waste materials, The collection and handling of laboratory specimens and Universal hygiene precautions
• Assist patients and colleagues in adopting good infection control measures and health and safety measures.
• Ongoing cleaning and sterilisation of clinical equipment and working surfaces, preparing treatment/consulting rooms prior to use.

Person Specification

Education/Qualifications

Essential:

• Good level of education including competent levels of numeracy and literacy.
• Evidence of ongoing training and personal development.
• Willingness to work towards further educational qualifications required for the role.
• Evidence of Working in/with Care Homes Development
• Experience of working directly in a community development context, adult health and social care, learning support, social housing, welfare rights, money advice and information services or public health.

Desirable:

• NVQ Level 3, Advanced level, or equivalent qualifications

Knowledge / Experience

Essential:

• Experience of working within a multi-disciplinary team.
• Experience of working with a variety of different stakeholders.
• Experience of working under pressure and managing varying workloads and changing demands.
• Able to undertake duties in an autonomous manner.
• Able to demonstrate knowledge and understanding of mental health legislation e.g. Mental Capacity Act.

Desirable:

• Knowledge of QOF and enhanced services

Key Skills

Essential:

• Demonstrate flexibility and adaptability to working in a dynamic environment.
• Advanced communication skills, being able to discuss difficult and possibly contentious issues with patients, relatives and health professionals.
• Able to analyse information received and determine best action.
• Able to drive across the locality.
• Able to transport and install small items of equipment.
• Able to use a range of a keyboard, IT packages and applications.

About Us

Invicta Health are a non-profit company, with a passion for primary care. We have a wide range of services such as hub-based GPs services, GP surgeries, services in Urgent Care Centres and A&E, a Community Primary Care mental health service, GP staff training service and the list is growing all the time.

We are formed by a federation of General Practitioners working in Canterbury and South Kent Coast areas of East Kent. Our aim is to provide local, high quality services for local people by collaborating with other established organisations in the health and social care community.

What perks can we offer you?

• NHS Pension
• Learning and Development opportunities
• Progression opportunities
• Competitive annual leave entitlement
• Incremental pay progression
• Flexible working
• Approved blue light card provider
• Salary Sacrifice Schemes
• Company Car Scheme
• Employee Assistance Programme

Job Type: Part-time

Salary: £12.59-£13.89 per hour

Expected hours: 22.5 per week

Schedule:

• Monday to Friday

Work Location: In person

Application deadline: 15/03/2024
Reference ID: MARSHPCNCHC