Role Description & Competencies: Care Co-ordinator
Care Co-ordinators work closely with GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. They focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.
What are the benefits of having a Care Co-ordinator in the team?
Care Co-ordinators provide extra time, capacity and expertise to support patients in preparing for or in following up clinical conversations that they have with primary care professionals. They provide co-ordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles. They also support the coordination and delivery of MDTs within PCNs.
Ensuring seamless service provision significantly decreases the risk of the patient deteriorating and thereby reduces the overall cost of care and the likelihood that additional interventions will be needed in future.
What is the maximum reimbursable amount for primary care organisations to recruit to this role?
£29,135 (with on costs) over 12 months
What is the recommended salary for a Care Co-ordinator?
In general practice the Care Co-ordinator’s salary can be negotiated, although there is a suggested starting salary of AFC Band 4 equivalent.
What can a Care Co-ordinators do in General Practice?
Care Co-ordinators can:
- Meet patients, patient carers and family members to discuss their personalised care requirements, the services available to them and the help they want
- Draw up personalised care and support plans in line with person-centred service plan (PCSP) best practice
- Contact other care departments/ agencies and ensure that services are delivered appropriately
- Amend care plans as necessary when difficulties arise
- Visit patients, checking on the care that they have received and documenting it accordingly
- Work with the care team to evaluate interventions and identify where and when further ones will be required
- Help people to manage their need, answering their queries and supporting them to make appointments
- Support people to access interventions that support them in their health and wellbeing, e.g training and employment, self-management education courses and peer support
- Help patients to access to appropriate benefits where eligible/ personal health budgets where appropriate
- Facilitate shared decision-making conversations by raising awareness of support tools
- Ensure that patients have good quality information to make choices about their care
- Support people to understand their level of knowledge, skills & confidence (Patient Activation level) when engaging with their health and wellbeing, including through use of the Patient Activation Measure (PAM*)
*The Patient Activation Measure (PAM) helps to measure the spectrum of knowledge, skills and confidence in patients and captures the extent to which people feel engaged and confident in taking care of their condition.
What are the skills and competencies required of the role?
- Knowledge of the core concepts and principles of personalised care, shared decision making, patient activation, health behaviour change, self-efficacy, motivation and assets-based approaches
- Active and empathetic listening
- Effective questioning
- Shared agenda setting/ collaborative goal setting/ shared follow-up planning
- Ability to build trust and rapport