Community Care Coordinator

Job overview

Northamptonshire has the ambition that our older population can be happy, healthy and able to maintain independence for as long as possible. Our older population tell us that it can be complicated and confusing to know where best to seek advice and support, that time is often needed to review wider health needs as opposed to ten-minute appointments and that social isolation and fear of ageing are major factors on wellbeing. We want to fix this to make sure that all of our older population have personalised and holistic support plans and have their own link person who will ensure timely support is available when needed. The bedrock of our change programme is to continue with the creation of local support teams matching the geographic areas covered by our Primary Care Networks (PCN). These teams combine staff from voluntary sector, adult social care and health, linked to a team of specialists, and led by the Frailty Specialist GP in each PCN.

For this role we are seeking to appoint to PCNs in the Northampton area (MWEB and Royal Parks) and there is a need to work on Mondays and Thursdays as part of the working pattern to be agreed with the successful candidate.

Main duties of the job

• Liaise with GPs and practice teams to identify persons who are elderly, frail or who have long term health needs and support
• Arrange, coordinate and undertake initial home visits and assessments of need within a patient's own home, making relevant referrals
• Undertake basic health checks such as weight, nutrition, blood pressure monitoring
• Support persons within the community to be able to remain as independent as possible within their own home and reduce the risk of crisis support.
• Tasks may include but not limited to assessment and provision of Iow level mobility aids, house clearance and cleaning, provision of items to meet basic needs such as emergency food parcels, supporting individuals with housing, finances, medication and follow up appointments.
• Coordinate and attend PCN Frailty Clinics.
• Work alongside families and a person's wider support network, ensuring their choices, needs and support within their own home are met as a long- term plan.
• Helping persons to access existing groups and events taking place within their communities.
• Document and monitor aspects of patient co-ordination and service delivery, supporting data collection and audit using the practices clinical system as well as organisational data Systems
• Maintain an individual case load whilst working cohesively alongside other Age Well partner organisations, supporting a collaborative approach

Detailed job description and main responsibilities

As a Community Coordinator in one of the local Age Well Teams you will be responsible for undertaking comprehensive holistic assessments of identified frail older people, usually in their own homes, to create personalised care plans which will assist the person to live well in their own environment, manage their long-term conditions, reduce isolation and improve their general wellbeing and quality of life. Candidates therefore need a range of experience, including hands on clinical care in a health setting, as a Health Care Assistant or similar, and be passionate about providing effective support to our older population within the community. A good understanding of services available both within the community and hospital and an interest in frailty so patients can be supported is essential. As a Community Coordinator you Will co-ordinate referrals to ensure patients within the locality receive excellent and timely support. The ability to develop close working relationships with other health and social care partners is an essential aspect of this role. Every team member will have direct access to their local Befriending lead, and lead support workers for Falls and for Dementia. Through additional training if required you will identify low level equipment needs and instruct for these to be provided and identify how technology can be used to maintain independence and help self management of long term conditions and instruct for digital solutions to be provided.

Applicant requirements

This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.