Wellbeing Care Coordinator - N&W PCN
Working closely with the patient and their GP, or other healthcare professional, the WBCC co-ordinates patients healthcare and directs them to the appropriate service to ensure that they get the most suitable care from whatever health or social care provider is appropriate.
The WBCCs role requires them to be able to work with, and understand the roles of, a variety of different people working in the practice and across the PCN including doctors, nurses, healthcare assistants, social prescribing link workers, physiotherapists, physician associates, paramedics, health and wellbeing coaches, occupational therapists and pharmacy technicians.
They will identify and work with individuals in need of proactive support with the aim of providing advocacy, encouraging independence, a healthy lifestyle, mental wellbeing, and social connectivity. They may be given a caseload of identified patients and be required to ensure that their changing needs are addressed by taking into account local priorities, health inequalities and/or population health management risk stratification.
This may include increasing uptake in cancer screening and other health initiatives, early intervention to manage long term conditions, and supporting people to access health, social and community services. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
They can provide extra time, capacity, and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals which will therefore involve them working one to one with patients who need extra support, helping them to be actively involved in managing their care and supported in making choices that are right for them.
The successful candidate will be caring, dedicated, reliable, 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.
There may be a need to work remotely depending on the requirements of the role. Main Responsibilities The following are the core responsibilities of the WBCC. There may be, on occasion, a requirement to carry out other tasks, as directed by your line manager.
This will be dependent upon factors such as workload and staffing levels. 1.Enable access to personalised care and support To work closely with practice and other healthcare roles, the PCC is to identify and work with a cohort of people to support their personalised care requirements, using any available decision support tools such as Simple Activation Questions (SAQs), templates and software To collate all of a patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice and based on what matters to the person To help people to manage their needs by answering their queries and supporting them in making appointments To assist patients to be better prepared to have conversations on shared decision-making and to improve awareness of shared decision making and related support tools To provide patients with high quality, easy to understand written and verbal information to assist them in making choices about their care and allow them to understand and build confidence in their own health and care management To support patients in understanding their level of knowledge, skills and confidence (known as activation level) when participating in their health and well-being using, where appropriate, the SAQ Have basic safeguarding processes in place for vulnerable individuals 2.Co-ordinate and integrate care Be the initial point of contact for all new referrals into the WBT and triage/allocate them to the most appropriate role and staff member within the Team.
To support people to access appropriate benefits where eligible as well as taking up employment and training Liaise with other WBCCs in other practices within the PCN and County to share best practice To assist patients to access self-management education courses, peer support or interventions that support them in their health and well-being Make onward referrals, if necessary, to other roles within the WBT or external services such as the Healthy Lifestyles Team or Adult Social Care.
Work closely with and develop strong relationships with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated delivery of the patients care plan, without requiring a further referral from the GP.Where appropriate, to assist patients to access personal health budgets To provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working hand in hand with social prescribing link workers To support in the delivery of enhanced services and other service requirements Organise, support and attend relevant meetings when required including multi-disciplinary team meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance.
Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update. To contribute to and embrace the spectrum of clinical governance 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 co-ordination on their health and wellbeing. Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives.
Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. 3.Patient Services Support the Wellbeing Team to deliver face to face, group and virtual group consultations to proactively target specific areas of health inequalities and long-term conditions.
To contribute to public health campaigns (e.g. flu clinics) through advice or direct care To be present at patient group meetings or other appropriate events to give advice. To provide services to patients via clinics in the PCN, domiciliary visits and in residential and nursing homes, and to deliver care plans that improve the quality of patient care.
To assist with the production of patient information leaflets and posters and support awareness projects throughout the year. To help plan, develop and support the introduction of new working processes within the PCN to optimise the patient uptake.
See attached job description for more information.