Integrated Care Community Care CoordinatorNHS

Job summary

37.5 Hours per Week - Fixed Term

Working Hours: Monday to Friday, 08:00am-16:00pm

Base: Barrow ICC, Fairfield Lane

An exciting opportunity has arisen to join the established Barrow Integrated Care Community (ICC) Clinical Team as a Band 5 Care Coordinator.

This role is ideal for an experienced health care professional who is passionate about delivering person-centred care and supporting people to remain independent within their own communities.

Working as part of a multidisciplinary team alongside Case Management, GPs, Community Nurses, Allied Health Professionals, Social Care and VCFSE partners, you will coordinate care for patients with frailty, long-term conditions and complex needs. You will support assessments, develop personalised care plans, coordinate referrals, signpost to appropriate services and act as a key point of contact for patients and carers.

You will help improve patient outcomes through proactive care coordination, effective communication and collaborative working, contributing to the prevention of avoidable hospital admissions and supporting the delivery of high-quality integrated care.

This is an exciting opportunity to join a developing ICC, with excellent opportunities for learning, professional development and helping shape the future of community services across the Barrow community.

Main duties of the job

As a Band 5 Care Coordinator, you will play a key role in delivering proactive, person-centred care across the Barrow ICC footprint. Working within a multidisciplinary team, you will coordinate care for patients with frailty, long-term conditions and complex health and social care needs.

Working alongside Case Manager, Development Lead, ICC Clinical Team Leader, GPs and partner organisations, you will support the assessment of patient needs, coordinate personalised care and support plans, facilitate referrals, and signpost patients to appropriate health, social care and voluntary sector services.

You will act as a central point of contact for patients and carers, supporting them to navigate services, promoting independence and self-management, and helping to prevent avoidable hospital admissions through timely intervention and coordinated care.

The role includes managing referrals, coordinating appointments, supporting safe hospital discharges, maintaining accurate clinical records, participating in multidisciplinary team meetings, escalating concerns appropriately and maintaining your clinical competencies through ongoing training, supervision and continuous professional development.

You will build effective relationships across health, social care and community services, ensuring patients receive the right care at the right time. Excellent communication, organisational and IT skills are essential, together with the ability to work independently and travel across Barrow.

Job description

• Coordinating a defined caseload of patients with long-term conditions, frailty and complex health and social care needs under the guidance of the multidisciplinary team.
• Supporting the coordination of care across health, social care and voluntary sector services to ensure seamless, person-centred care delivery.
• Assisting patients to maintain their independence and wellbeing through proactive care coordination, personalised support and timely interventions.
• Supporting the development, implementation and review of personalised care and support plans in partnership with patients, carers and the wider multidisciplinary team.
• Providing information, advice and signposting to appropriate health, social care and community services to help patients access the support they need.
• Promoting person-centred care and supporting patients to make informed decisions about their health and wellbeing.
• Supporting proactive identification of patients who may benefit from coordinated care and early intervention, contributing to population health management initiatives and reducing avoidable hospital admissions.
• Participating in population health activities, health promotion initiatives and public health events across the Integrated Care Community (ICC), supporting the delivery of preventative care and improving health outcomes within local communities.
• Monitoring patient progress, maintaining accurate and timely clinical records, and escalating changes in patient needs or identified risks to the appropriate clinician.
• Developing effective working relationships with colleagues across primary care, community services, acute care, social care and the voluntary, community, faith and social enterprise (VCFSE) sector to support integrated, coordinated care.
• Providing day-to-day support and guidance to Band 4 Care Navigators, promoting effective team working, sharing knowledge and contributing to the smooth running of the service within the scope of the role.
• Supporting the Case Managers by undertaking delegated activities and, where appropriate, providing operational support and coordination during periods of planned or unplanned absence to ensure continuity of patient care and service delivery.
• Contributing to service improvement initiatives and the continued development of Barrow ICC, whilst actively participating in learning, reflective practice and ongoing professional development.

About us

We operatefrom three main hospitals-Furness General Hospital (FGH) in Barrow, the Royal Lancaster Infirmary (RLI), and Westmorland General Hospital (WGH) in Kendal, as well as a number of community healthcare premises including Millom Hospital and GP Practice, Queen Victoria Hospital in Morecambe, andUlverstonCommunity Health Centre.

FGH and the RLI have a range of General Hospital services, with full Emergency Departments, Critical/Coronary Care units and various Consultant-led services.

WGH provides a range of General Hospital services, together with an Urgent Treatment Centre, that can help with a range of non-life threatening conditions such as broken bones and minor illnesses.

All three main hospitals provide a range of planned care including outpatients, diagnostics, therapies,daycase and inpatient surgery. In addition, a range of local outreach services and diagnostics are provided from community facilities across Morecambe Bay.