Health and Wellbeing Team Clinical Care Coordinator

Job summary

An exciting opportunity has arisen for an experienced HCA / Care Coordinator to join the award-winning TWNS Health and Wellbeing Team as an expansion to our hugely successful team. This multi-disciplinary team is focused on proactive care and making a real difference for the lives of our patient family across our PCN. Focused on frailty, dementia, and patients with newly diagnosed cancer, the team have been asked to showcase their work locally, regionally, nationally, and internationally.

The TWNS Health and Wellbeing Team, led by our highly experienced and talented Lead Nurse, is comprised of two Health and Wellbeing Coaches and well supported by all our practices, the PCN Clinical Directors, and our PCN Project Care Coordinator. The team was first established in January 2022 and has evidenced significant benefits for our patients, and we're thrilled to be able to expand further following support from our local Gloucestershire Integrated Care System.

This is a clinical role and an integral part of the PCN's multidisciplinary team, working under the Lead Nurse and alongside our Health and Wellbeing Coaches, to provide an all-encompassing approach to personalised care embedding the proactive and personalised care approach across the PCN.

Main duties of the job

Please note this job will close early once sufficient applicants have been received.

We're looking for an experienced HCA or Care Coordinator to support the team across all aspects of the team's work, undertaking functions such as:

1. Regular and frequent face-to-face and telephone conversations completing assessments with patients, under the direction of the Lead Nurse.
2. Utilising and establishing systems to coordinate patient access to services.
3. Enabling smooth and planned transfer between care settings.
4. Providing advice, information, and signposting to services.
5. Overseeing safeguarding administration and communication with partner organisations where required.
6. Ensuring personalised health and care planning is proactive, supportive, and patient-centred.

Successful candidates will be adept at SystmOne, able to vaccinate and take bloods, are caring, dedicated, reliable, and person-focused and enjoy working with a wide range of people.

They will have good written and verbal communication skills and strong organisational and time management skills.

They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team, and committed to providing people, their families, and carers with high-quality support.

The HCA or Care Coordinator will have a key role in a small, but dynamic and vibrant, team, supporting the delivery of excellent proactive care.

About us

TWNS PCN supports over 50,000 patients registered at one of our five practices: Church Street, Mythe Medical, Newent, Staunton & Corse, and West Cheltenham Medical.

The team are embedded at the heart of our five practices, building longstanding relationships with the local diverse community and providing lifelong care across this broad geographical community.

The TWNS PCN team is committed to understanding and responding proactively to the needs of the most vulnerable patients, supporting them to enjoy good health and independence for as long as possible.

Come and work with us and be part of this innovative, award-winning, and dynamic team, working in partnership with patients and enabling excellent care.

Job description

Job responsibilities

This Care Coordinator position is a critical post in the continued success of the award-winning TWNS PCN's Health and Wellbeing Team. The team are embedded at the heart of our five practices, building longstanding relationships with our local diverse community and providing lifelong care across this broad geographical community. The team are committed to understanding and responding proactively to the needs of our most vulnerable patients, supporting them to enjoy good health and independence for as long as possible.

This clinical role is an integral part of the PCN's multidisciplinary team, working under the Lead Nurse and alongside our Health and Wellbeing Coaches, to provide an all-encompassing approach to personalised care; promoting and embedding the proactive personalised care approach across the PCN.

The role provides a central coordination function for patient care planning: undertaking both face-to-face and telephone appointments with patients, performing routine clinical tasks such as phlebotomy, BP monitoring, and supporting some of our associated patient groups, as required. In addition, the role oversees safeguarding administration, document handling, record management, and communication with partner organisations across health and social care.

Main Responsibilities

1. Facilitate and ensure the effective delivery of proactive, patient-centred, personalised care for identified cohorts of patients across the breadth of the work of the Health and Wellbeing Team, inclusive of frailty, dementia, and cancer. This will involve monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate timeframes.
2. Explain the management of a patient's pathway, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms.
3. Work closely with all relevant care agencies (primary care, secondary care, community services, voluntary services, and other relevant service providers) to ensure coordinated delivery of the patient's care plan, without requiring a further referral from the GP.
4. Maintain accurate records and statistical returns as determined by the Lead Nurse, including providing patient-related information for entering into SystmOne, within the required timeframe.
5. Adhere to infection prevention control policies.
6. Collect data on patients/carers for recognised outcome measures and document for service interpretation. Ensure all patient notes are updated to reflect any changes, including details on plans.
7. Organise and attend relevant meetings when required including supervision, PCN meetings, multi-disciplinary team meetings etc., ensuring that any necessary documentation is circulated in advance.
8. Contribute to audits and data collection to aid evaluations of the PCN services.
9. Advise patients on diet, lifestyle as well as physical and mental wellbeing, along with signposting to local services and funding they may be eligible to access.
10. Be a contact point for the TWNS PCN's practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders.

Person Specification

Qualifications

Essential

• GCSE English and Mathematics (or equivalent level).
• Enrolled in (or willing to), undertaking or qualified from appropriate training for Care Coordinators, as set out by the Personalised Care Institute.
• Clinical skills and qualification at HCA level (minimum level 2) or able to demonstrate experience to equivalent level.
• Demonstrable commitment to professional and personal development.
• Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook.
• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities.
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential.
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies, and stakeholders.
• Ability to identify risk and assess/manage risk when working with individuals.
• Ability to work from an asset-based approach, building on existing community and personal assets.
• Ability to maintain effective working relationships and promote collaborative practice with all colleagues, demonstrating personal accountability, emotional resilience and work well under pressure.
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.

Desirable

• Experience or training in personalised care and support planning.
• Experience of data collection and using tools to measure the impact of services.
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.
• Knowledge of the personalised care approach.

Experience

Essential

• Experience of working directly in a care coordinator or HCA role, using SystmOne, in a primary or community care setting.
• Experience of working within multi-professional team environments.

Desirable

• Experience or training in personalised care and support planning.
• Experience of data collection and using tools to measure the impact of services.
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.

Other Essential Information

Essential

• Meets DBS reference standards and criminal record checks.
• Willingness to work flexible hours when required to meet work demands.
• Access to own transport.
• Ability to travel across the PCN as required.
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities.
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential.
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies, and stakeholders.
• Ability to identify risk and assess/manage risk when working with individuals.

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
TWNS PCN
Address
1ST Floor the Deveruex Centre
Barton Road
Tewkesbury
Gloucestershire
GL20 5GJ
Employer's website