Care Coordinator advertised by

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G Doc Ltd

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G Doc Ltd
Quayside House
Quay Street
Eastgate Street

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Contact details
Laura Thomas

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Care Coordinator - J180-A0782-22-6300


Job summary

We have two full time positions available within the Primary Care Network (PCN). The available positions are at Pavilion Family Doctors and at Gloucester Health and Access Centre. Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

This role is intended to become an integral part of the PCN’s multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

The Care Coordinator will help identify the patients’ health and social care needs and will help signpost them to the appropriate services to ensure that they get the most suitable care and support from whichever health or social care providers are appropriate.

There may be a need to work remotely depending on the requirements of the role.

Main duties of the job

As a PCN Care Coordinator you will take referrals for individuals or proactively identify people who could benefit from support through carecoordination. You would be required to have a positive, empathetic and responsive conversation with the person and their family and carer(s) about theirneeds.

You will be Working towards increasing patients’ understanding of how to manage and develop health and wellbeing through offering advice and guidance.

You will need to develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right forthem alongside work with the wider PCN, MDTs, and the social prescribing serviceto look at how Carers can support people.
You will need to Support people to develop and implement personalised care and supportplans whilst reviewing and updating them on regular intervals You will ensure the personalised care and support plans are communicated to the GP and any other professionals involved in the person’s care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMEDcodes

About us

Gloucester Inner City PCN currently consists of four central city practices - Gloucester Health Access Centre (GHAC), Kingsholm Surgery, Severnside Side Medical Practice and Partners in Health. Working with the PCN is a real opportunity to develop and hone skills, and build valuable and diverse experience in this growing and vibrant city centre network.

Job description
Job responsibilities

The following are the core responsibilities of the PCN Care Coordinator. There may on occasion be a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels:

• To provide personalised support to patients with frailty and specifically care home residents, their families and carers enabling them to take control of their wellbeing and improve their health outcomes
• To manage and prioritise your own caseload in accordance with the needs, priorities and any urgent support required by individuals on the caseload
To work with frail and care home residents and carers to co-produce a simple personalised support plan identifying health and social care needs
• To provide targeted support and proactive reviews for vulnerable, complex patients and those at risk of admission and re-admission to secondary care
• To manage a caseload of potentially complex patients and to provide advice for the GP management on the more complex patients

• Support the PCN team with identifying community pathways that might prevent hospital admission and identify potential gaps in care

• To take referrals from a wide range of agencies, working with GP practices within primary care networks, pharmacies, multi-disciplinary teams, hospital discharge teams, allied health professionals and social care services

• Be responsible for arranging, attending and minuting Care home Multi-Disciplinary Team meetings

• Proactively prepare any actions prior to the MDT ensuring all relevant clinicians are present and follow-up on actions

• To record patient interventions on relevant electronic database systems and contribute to report generation, analysis and production

• Be responsible for logging and making referrals

• To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN team and providing information to any member of the PCN team in order to ease processes and communication in agreement with data protection protocol

• To build relationships with key staff in all GP practices within the local PCN, attending relevant meetings, becoming part of the wider network team, giving information and feedback on social prescribing
• To support in the delivery of enhanced services and other service requirements on behalf of the PCN
• To work collaboratively with other teams and services to maintain an effective and efficient service
• To plan / organize work using own initiative, whilst being able to work as a valuable member of a team
• To have excellent IT skills, to include Microsoft Office, Outlook and Excel
• To undertake general office duties to support the role
• To ensure all electronic records are updated and complete within the agreed timescales
• To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleague
• Support the PCN team by inputting into the overall strategy development and programming of work streams by applying knowledge and understanding of program and project management
• Work towards completing the appropriate training to deliver and support the Comprehensive Model for Personalised Care
• Work closely and in partnership with the Social Prescribing Link Worker(s)
• To participate in the review and appraisal process
• To carry out any other reasonable duties as requested by a manager to ensure quality of service
• To participate in any relevant training/courses/conferences
• Complete mandatory training
• Use clinical systems for record keeping, audit and evaluation
• Develop and implement data collection systems that will provide accurate and timely data.
• Maintain confidentiality

In addition to the primary responsibilities, the Care Coordinator may be requested to:

a. Support delivery of QOF, incentive schemes, QIPP and other quality or cost effectiveness initiatives.
b. Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
c. Duties may vary from time to time without changing the general character of the post or the level of responsibility.

Person Specification

NVQ Level 3, advanced level or equivalent qualifications or working towards Demonstrable commitment to professional and personal development


Training in motivational coaching and interviewing or equivalent experience


Experience of working directly in a community development context, older adult health and social care, learning support or public health/health improvement (including unpaid work) Experience of working with the VCSE sector (in a paid or unpaid capacity), including with volunteers and small community groups Experience of partnership/collaborative working and of building relationships across a variety of organisations


Experience of supporting people with their mental health, either in a paid, unpaid or informal capacity Experience of data collection and providing monitoring information to assess the impact of services

Personal Qualities and Attributes

• Ability to listen, empathise with people and provide person- centred support in a non-judgemental way.
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity.
• Commitment to reducing health inequalities and proactively working to reach people from all communities.
• Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
• Demonstrate personal accountability, emotional resilience and works well under pressure

Skills and Attributes

Knowledge of the personalised care approach Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities

Polite telephone manner Knowledge of NHS IT systems, including Microsoft office, emails and the internet to create simple plans and reports

Knowledge of motivational coaching and interview skills Ability to work as a team member and autonomously

Motivating others to reach their potential Ability to use own initiative, discretion and sensitivity

Ability to communicate complex and sensitive information effectively with people at all levels by telephone, email and face to face

The ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety Willingness to work flexible hours when required to meet work demands


Knowledge of VCSE and community services in the locality

Contract type:  Permanent
Full-time equivalent (FTE):  37.5
Working pattern:  Full Time, Flexible working
Payscheme:  Other
Staff group:  Additional services
Application method:  Online applications

Job location 1

Gloucester Health and Access Centre
Quayside House
Quay Street

Job location 2

Pavilion Family Doctors
Stroud Road

For more details, to view the Job Description and to apply, please click on the Apply Now button.

Closing date for applications: 01/07/2022

Salary: £20,000-£23,500 Depending on experience

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