CLINICAL PRACTICE CARE COORDINATOR

This post is offered to support existing Care Coordinator colleagues in St Peters Hill Surgery in Grantham to increase capacity to support people in their own homes and within care home settings.

The role will be employed within K2 Healthcare and based within the Grantham Neighbourhood Hub.

Main duties of the job

The role of the Practice Care Co-ordinator is to support both the practice staff and members of the Neighbourhood Team to identify and support people to reduce the risk of unplanned hospital admissions and to effectively support those individuals in the community.

To work dedicated hours to focus on proactively case managing people and being the preferred point of contact for the patient and Neighbourhood Team to achieve the following objectives:

1. To be a pro-active member of the Integrated Neighbourhood Team and Southwest Primary Care Networks.
2. To pro-actively engage with people deemed to be at risk of hospital admission or health deterioration.
3. To proactively engage with frequent fliers those attending A&E and utilising OOH services.
4. To pro-actively engage with HomeFirst Teams to reduce length of stay in acute hospital settings.
5. To pro-actively engage with people living in care home settings.
6. To be the key contact within the GP Practice environment.

About us

K2 Healthcare is a GP federation constituted of 16 member GP Practices in South West Lincolnshire with two Primary Care Networks and supporting a population of 133,000 people.

K2 works together to share resources and expertise that enable practices to provide shared services and business systems to provide the best possible care for our population, ensure sustainability, growth and value for GP practices and system partners within available resources.

The Better Lives Lincolnshire Integrated Care System sees us working in a provider collaborative with the Primary Care Network Alliance, Secondary Care, Community Health, Mental Health, Social Care as well as Local Authorities, and the Community and Voluntary Sector.

How we do it is as important as what we do and relationships with our partners is at the core of everything we do.

Neighbourhood Working describes an integrated approach to managing patients, through a blended workforce that encompasses both health and social care; to include acute, voluntary and community sectors where barriers to working are negated, the health and wellbeing needs of the individual are at the centre of decision-making, care is proactive and not reactive, and services are provided in a timely manner.

Job responsibilities

ROLE SUMMARY

Neighbourhood Working is a new way of strengthening and redesigning community services for a local population. It empowers people and communities to take an active role in their health and wellbeing, with greater choice and control over the care they need. It also supports the improvement, integration, and personalisation of services in Lincolnshire.

Core Neighbourhood Working Principles

1. Having a different conversation
2. Enabling self-care and peer support
3. Recognising what's important to me
4. Assessing immediate needs and addressing barriers to improve quality of life

To liaise with the registered GP and other practice based staff in addition to all other providers and services utilising, where appropriate, a multi-disciplinary approach.

To implement and review individual care plans, self-management plans in liaison with the GP practice team. To include advanced care plans, Respect documents, personalised care and support plans.

Plan and monitor those on GP caseloads and directed by the practice team or identified by the wider Neighbourhood Team at risk of deterioration.

Provide enhanced support to Nursing and Residential homes with a focus on strengthening relationships and improving access through information sharing, education, and advice.

To ensure all people in Nursing and Residential homes have care plans including advanced care plans, Respect documents, personalised care, and support plans and to provide a holistic review of all people in these homes with updates of their plans.

KEY RESPONSIBILITIES

1. Act as a point of contact between the GP Practice Team, Neighbourhood Team, people and their carers.
2. Develop and maintain a detailed knowledge of local services to enable supported signposting of people with identified need, sharing information with the Neighbourhood Team/Primary Care Network.
3. Liaise with GPs and practice teams to identify people who are elderly, frail or who have long term health need and support.
4. Support the early identification of those with life limiting conditions including those with palliative and end of life symptoms and conditions in order that they are supported to achieve a good end of life experience.
5. Liaise with primary, secondary and specialist care services as required.
6. Work with Neighbourhood Team colleagues to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.
7. Provide these cohorts of people signposting to identified services to maintain their independence and improve their health and well-being.
8. Visit people in community, home, or care home settings to assess and discuss their care needs involving carers as appropriate.
9. Implement personal care plans for individual people, ensuring preventative actions are detailed to support the appropriate use of services.
10. Communicate the care plan to the GP and any other members of the Neighbourhood Team involved in the person's care and upload to the relevant records.
11. Ensure that identified people receive the right level of help at the right time and help them to experience a joined-up service by liaising with relevant members of the Neighbourhood Team.
12. Work with the patient, carers and the Neighbourhood Team to encourage the patient to adopt effective self-management and self-help seeking approaches to reduce unnecessary hospital admissions.
13. Liaise with other agencies to ensure timely and appropriate engagement as required.
14. Support people to access community care assessments as well as carers assessments.
15. Where a personal healthcare budget is allocated provide advice as required regarding the key choices the patient will need to make.
16. Identify unpaid carers and direct them to access services as appropriate to provide them with support.
17. Identify when urgent action or a step up in care is required and promptly alert the relevant member of the Neighbourhood Team, highlighting any safety concerns.
18. Follow up on communications from out of hospital and in-patient services regarding changes in condition of people to support the practice to respond proactively to potentially unmet needs.
19. Undertake visits or telephone contact to manage people on the PCC's case load following any unplanned hospital admissions where appropriate.
20. Participate in Practice multi-disciplinary meetings to discuss people actively being managed by the Neighbourhood Team and any other people from the PCC's case load needing discussion.
21. To attend Neighbourhood Team MDT meetings plus any other meetings. Updates between meetings to be shared with the Neighbourhood Team colleagues.
22. Maintain accurate and up to date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e. entering notes onto SystmOne using agreed read codes.
23. To run regular patient searches using SystmOne to have an up-to-date record of progress of achievement of Key Performance Indicators in line with practice based recording and reporting requirements. Support the Practice Managers in providing KPI reports for submission as requested.
24. Work with K2 Federation Southwest Primary Care Networks, Neighbourhood Team and other agencies to support and further develop this role.

KEY WORKING RELATIONSHIPS

1. Practice teams
2. Neighbourhood Team
3. Care Homes
4. Community health services
5. Mental Health and Learning Disability Services
6. Hospital teams including ward, A&E, discharge and AIR teams
7. Safeguarding agencies
8. Integrated Care Board
9. Adult Social Care
10. Social Prescribing Teams
11. Voluntary Services
12. Independent Care Homes
13. Local Authority teams
14. Housing Providers
15. Independent living teams

Person Specification

• Ability to effectively organise own workload and that of others with minimum supervision
• Ability to achieve goals with deadlines.
• Ability to work autonomously as well as within a team
• Ability to make decisions under pressure
• Ability to work sensitively to maintain high levels of diplomacy and confidentiality
• Enthusiasm, drive and the ability to cope in challenging situations
• Demonstrated capability to plan over short, medium and long-term timeframes and adjust plans and resource requirements accordingly
• Experience of setting up and implementing internal processes and procedures
• Ability to prepare and produce concise yet insightful communications for dissemination to senior stakeholders and a broad range of stakeholders as required
• Excellent communication skills, listening, written and verbal.
• Negotiation and conflict management skills and the ability to influence in formal settings
• Demonstrated capabilities to manage own

Qualifications

• Registered Health or Care Professional
• Post graduate study in health-related studies relevant to long term conditions or equivalent experience
• Evidence of continuing professional development
• Post registration teaching qualification or willingness to undertake

Skills and Knowledge

• Excellent communication skills, listening, written and verbal.
• Good organisational and planning skills.
• Excellent prioritisation skills and ability to work to tight deadlines.
• Skilled and sensitive communicator, confident in dealing with staff, people and service users
• Ability to deal with complex facts/situations, requiring analysis, interpretation and comparison of a range of options.
• IT skills including Good working knowledge and application of Microsoft Office packages
• Understand the wider determinants of health

Experience

• Experience of dealing with people with long term conditions.
• Evidence of ability to work autonomously.
• Evidence of working within a multidisciplinary team
• Evidence of teaching or mentorship
• Evidence of complex case management and multiagency working.

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.