Job description

Job responsibilities

Key responsibilities

• Provide one-to-one and group health coaching support for people with one or more long-term conditions, based on what is important to them, with the aim of: improving peoples knowledge, skills, confidence in managing their condition/s, empowering people to manage their own health and improve their health outcomes.and support them in making changes in their health related behaviour.
• Manage and prioritise a caseload, in accordance with the needs, priorities and support required by individuals in the caseload. It is vital that you have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the health and wellbeing coach role e.g. when there is a mental health need requiring the patient to be referred to an appropriately qualified practitioner.
• Work as part of a multidisciplinary multi-agency team to promote health coaching and to be ambassadors for Personalised Care and Supported Self-Management, modelling the coaching approach in their work.
• Ensure that GPs, practice nurses, practice pharmacists and other members of the primary care team understand the Health and Well-being Coach role, how to refer to them, and which patients may particularly benefit from health coaching.
• Support local health, social care and voluntary sector professionals to make appropriate referrals to the service. Promote and raise awareness of the health coaching service particularly to groups and communities that experience barriers to access.
• Attend and contribute to team, practice, and PCN meetings and events as required by the service.
• Work flexibly, adapting to the needs of the service and client group while maintaining the integrity of the role.
• Contribute to and take part in health coaching train-the-trainer workshops in order to spread health coaching skills to support a mindset shift among staff in how they have conversations, integrating a health coaching approach into how they work with people and each other, and to strengthen a shift towards enabling a compassionate and coaching culture in their organisation.
• Collect service user experience and impact of health coaching as part of the delivery of personalised care. Participate and collect information that measures the impact of health coaching as an intervention that supports embedding personalised care into local health systems e.g. collect data entry relating to the health coaching activity in GP, Local Authority, and hospital clinical systems or other systems, as required.

Key Tasks

Provide personalised support

• Meet people on a one-to-one or group consultation basis, by phone, video conference, or face-to-face.
• Give people time to tell their stories and focus on what matters to the person.
• Build trust and respect with the person, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices.
• Work from a strength-based approach focusing on a persons assets.
• Use a structured framework/model approach to coach individuals across a series of sessions to: identify whats important to them; set personal goals and appropriate steps; build skills and confidence to achieve goals; and use problem-solving to work through challenges.
• Work with the principles of self-management to actively support:

Shared decision making with healthcare professionals.

Effective engagement with personalised health and care plans.

proactive engagement with self-management education and peer support;

Proactive engagement with self-management education and peer support.

Proactive engagement with social prescribing, connecting people to community-based activities which support their health and wellbeing.

Proactive engagement with individually sourced activities and support.

Access to a care-coordinator and/or a personal health budget, where needed.

Referrals

• Promote health coaching, its role in supported self-management as a part of personalised care, in addressing health inequalities and the wider determinants of health.
• As part of the PCN multidisciplinary team, build relationships with staff in GP practices within the local PCN, attending relevant multidisciplinary meetings, giving information and feedback on health coaching.
• Be proactive in developing strong links with all local organisations to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals.
• Work in partnership with local agencies to raise awareness of health coaching and how improving peoples knowledge, confidence, skills can enable them to improve their ability to manage their long-term conditions and reduce reliance on clinical services.
• Provide referral organisations with regular updates about health coaching, including information on how to encourage appropriate referrals.
• Seek regular feedback about the quality of service and impact of health coaching on referral agencies.
• Be proactive in encouraging equality and inclusion and case-finding, through self-referrals and connecting with all diverse local communities, particularly those communities that statutory bodies may find hard to reach.

General Tasks

Gathering and Reporting Information

• Work sensitively with people, their families and carers to gather key information, enabling tracking of the impact of health coaching on their health and well-being.
• Encourage people, their families and carers to provide feedback and to share their stories about the impact of health coaching on their lives.
• Support referral organisations to provide appropriate information about the person they are referring. Provide appropriate feedback to referral agencies about the people they referred.
• Work closely within the multidisciplinary team and with GP practices within the PCN to ensure that the relevant SNOMED codes to record activity are inputted into clinical systems (as outlined in the Network Contract DES), adhering to data protection legislation and data sharing agreements.

Supervision/ Professional development

• Have access to relevant GPs to discuss patient related concerns, and be supported to follow appropriate safeguarding procedures.
• Have access to individual and group coaching supervision from a suitably qualified or experienced health coaching supervisor.
• Know and adhere to organisational policies and procedures, including confidentiality, safeguarding, vulnerable adults, lone working, information governance, equality, diversity and inclusion training and health and safety.

Miscellaneous

• Establish strong working relationships with GPs and practice teams and work collaboratively with other Health and Well-being Coaches, Care Coordinators and Social Prescribing Link Workers, supporting each other, respecting each others views and meeting regularly as a team.
• Act as a champion for health coaching as a part of the PCNs personalised care offer for patients and organisations.
• Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.
• Identify opportunities and gaps in the service - and review risks and issues that could impact on service delivery - and provide feedback to continually improve the service and contribute to business planning.
• Contribute to the development of policies and plans relating to equality, diversity and health inequalities.
• Work in accordance with the practices and PCNs policies and procedures.
• Contribute to the wider aims and objectives of the PCN to improve and support Primary Care.

Person Specification

Experience

Essential

• Demonstrable skills in supporting behaviour change.
• IT literate, including ability to use all Microsoft platforms (Outlook, Word, Excel, Teams, Powerpoint etc).
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
• Able to work as part of a team.
• Excellent organisational and administration skills
• Working in a multi-disciplinary setting where influence and negotiation is required.
• Knowledge/familiarity with medical terminology.
• Working in a busy and demanding environment whilst delivering in a timely manner.
• Understanding of current issues facing the NHS.

Desirable

• A minimum of two years Primary Care experience.
• Experience of EMIS Web and other clinical systems such as AccuRX.
• Experience of using coaching approaches/frameworks and models or
• other helping strategies e.g. Motivational Interviewing.
• An understanding of the psychophysiology model of health and the social determinants of health.
• Experience of successful partnership working across statutory, voluntary and community sector.

Qualifications

Essential

• Be willing to attend training with a non-clinical Supported self management health coaching skills programme (minimum 4 days) by a Personalised Care Institute (PCI) accredited trainer or organisation prior to taking referrals.

Desirable

• Coaching/counselling qualification/experience or other relevant qualification/experience involving reflective listening skills relevant training and experience in non-clinical Supported Self-Management (SSM) Health Coaching through a PCI-accredited organisation.

Personal qualities and attributes

Essential

• Kind, reflective and self-aware.
• Demonstrates their belief that people have untapped resources within them that can only be unleashed by providing a non-judgemental and empowering service.
• Starts with what is working well and takes an asset-based approach (able to work from strengths) in all their interactions with people, colleagues and the communities we serve.
• Excellent communicator and influencer (able to build rapport with people easily).
• Operates with integrity and openness.
• Values diversity and difference.
• Understanding of and commitment to equality of opportunity and good working relationships.
• Commitment to continuous learning and development.
• Commitment to and focused on quality, promotes high standards in all they do.

Skills and knowledge

Essential

• A good understanding of the evidence base and development of self-management in the UK Understanding of the importance and process of helping people with long-term conditions to develop their knowledge, skills and confidence in managing their health and the range of models and tools available.
• Understanding how to apply health coaching in group settings.
• Able to work within a psychophysiology model, using a range of tools and techniques to enable and support people, such as agenda setting, goal setting,problem solving.
• Demonstrable skills in supporting behaviour change.
• Excellent group and one-to-one facilitation skills including conflict resolution.
• Skilled in active and reflective listening, building trust and rapport quickly.
• Good people management skills.
• Ability to work with minimal supervision and act decisively and ask for help when needed.
• Excellent communication and presentation skills.
• Proficient in Microsoft Office and web-based services.
• Ability to travel across multiple sites.

Desirable

• Proficient speaker of another language to aid communication with people in the community for whom English is a second language.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

North Sedgemoor PCN

Address

Axbridge & Wedmore Medical Practice

The Surgery, Houlgate Way,

Axbridge,

Somerset

BS26 2BJ

United Kingdom

Job description

Job responsibilities

Multi-Disciplinary Teams

• Overall responsibility for arranging the daily PCN led MDT meetings and the smooth running of integrated care within the team setting. A key role of the Care Coordinator is to ensure that all new referrals are identified, and information circulated to team members in advance of the meeting.
• Take notes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
• Manage reporting required and associated within the NHSE DES specifications for required services.

Patient Identification.Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care

• Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.
• Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the daily MDT meetings.
• Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT.
• Signpost team members, service users and carers to relevant services.

Direct patient facing work

• Support with the administration and patient management of the Community Investigation Hub, which provides a number of medical services for our patients within our neighbourhood.
• Manage a caseload of patients identified through the MDT or practice.
• Support patients to utilise decision aids in preparation for a shared decision-making conversation.
• Holistically bring together all of a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
• Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
• Support people to take up training and employment, and to access appropriate benefits where eligible.
• Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and well-being, including through the use of the Patient Activation Measure.
• Assist people to access self-management education courses, peer support or interventions that support them in their health and well-being and increase their activation level.
• Explore and assist people to access personal health budgets where appropriate.
• Refer or liaise with the Health Coaches and Village Agents as appropriate.

Communication and collaborative working relationships

• Demonstrate ability to work as a member of a team.
• Can recognise personal limitations and refer to more appropriate colleague(s) when necessary.
• Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.
• Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations.
• Work with service users, PCN practices and partners e.g., Care Homes to ensure new referrals are logged and allocated.
• Develop excellent working relationships with all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT.
• Act as a point of contact for residents, families, carers and professionals who visit the care home, such as MDT members and in-reach specialists.
• Meet regularly with the clinical lead and review case load and MDT function.
• Keep the MDT and OHP organisation abreast of good news stories.
• Provide background information about individuals for the daily MDT meetings.
• Communicate effectively with service users and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and well-being coaches, and other primary care professionals.
• Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT.

Other responsibilities

• To act at all times in an anti-discriminatory manner.
• To be able to plan and respond to workload according to operational priorities.
• To support the delivery of these functions across wider locality areas where necessary.
• To undertake any training required to maintain competency including mandatory training.
• To contribute to, and work within a safe working environment.
• The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures.
• The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.
• The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.

Patient Care

• Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding.
• Effectively use all methods of communication and be aware of and manage barriers to communication.
• Effectively recognise and manage challenging behaviours, carers and or relatives
• Provide information to patients, their carers and/or relatives on behalf of the team.
• The PCN will ensure the PCNs Care Coordinator can discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g., abuse, domestic violence and support with mental health) with a relevant GP.

Supporting Care Delivery

• Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated.
• Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc.
• Follow through with service users and others involved to ensure all services and care arrangements are in place.

Autonomy/Scope within Role

• The post holder will be required to work within clearly defined organisational protocols, policies and procedures.

Key Relationships

Key Working Relationships Internal

• Clinical Lead for the MDT.
• GPs and General practice teams within the PCN.
• PCN Care Coordinator Team Leader.
• PCN Manager.
• MDT members including but not exhaustive: Clinical Pharmacists, technicians, District Nurses, LARCH Team, OPMH, IRT, Adult Social Care, Paramedics, Social Prescribing Link Workers, Village Agents.

Key Working Relationships External

• GPs from neighbouring PCNs.
• Service providers.
• Social care.
• Voluntary services.
• Patients/service users.
• Carers/relatives.

Health and Safety/Risk Management

• The post-holder must comply at all times with the organisation and Practices Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System.
• The post-holder will comply with the Data Protection Act (1984), The General Data Protection Regulations (2018) and the Access to Health Records Act (1990).
• The post-holder will comply with all necessary training requirements relevant to the role as identified by the organisation; in particular the post holder must complete the specified care coordinator training delivered by the Personalised Care Institute.

Equality and Diversity

• The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc.

Respect for Patient Confidentiality

• The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.

Special Working Conditions

• The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies.

Person Specification

Qualifications

Essential

• GCSEs/Diploma/ HNC level (or relevant experience).
• Ongoing internal and external training to keep up to date with changes/ developments.

Desirable

• NVQ Level 3 Business Administration (or relevant experience).

Experience

Essential

• A minimum of two years Primary Care experience working with health professionals within administration or reception roles.
• Experience of EMIS Web and other clinical systems such as AccuRX and C the Signs.
• IT literate, including ability to use all Microsoft platforms (Outlook, Word, Excel, Teams, Powerpoint etc).
• Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
• Able to work as part of a team.
• Excellent organisational and administration skills
• Working in a multi-disciplinary setting where influence and negotiation is required.
• Knowledge/familiarity with medical terminology.
• Working in a busy and demanding environment whilst delivering in a timely manner.
• Understanding of current issues facing the NHS.

Desirable

• Understanding and experience of TeamNet.
• Able to use NHS Choices website effectively.
• Understanding of health and social care processes.

Values, Drivers and Motivators

Essential

• Willingness to undergo further training or development.
• Requires a flexible approach, and a highly motivated post holder. The role may need to be reviewed and developed in the future in line with changing priorities.
• Access to and ability to use transport as travel between sites across the county will be required for meetings and training.
• Willingness to undergo further training and development as the job develops.

Aptitude and Personal Qualities

Essential

• Professional attitude and assertive approach.
• Committed to development.
• Conscientious, hardworking and self- motivated to work with minimal supervision.
• Creative and tenacious in finding solutions to difficult problems.
• Ability to work with information, clinicians, social workers and managers.
• Ability to meet deadlines and work under pressure.
• Ability to engage and sustain relationships with all professionals, other organisations and service-users.
• Approachable and flexible.
• Honest and reliable.
• Enthusiastic.
• Sensitive to patients needs.
• Adaptable to change.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

North Sedgemoor PCN

Address

Axbridge & Wedmore Medical Practice

The Surgery, Houlgate Way,

Axbridge,

Somerset

BS26 2BJ

United Kingdom

Job description

Job responsibilities

Clinical:

• Undertake structured medication reviews for patients with complex polypharmacy, long term conditions and frailty.

• Prescribe safely and appropriately within scope of competence.

• Support Enhanced Health in Care Homes, including medicines reviews and participation in ward rounds.

• Reconcile medicines after hospital discharge and support safe transfer of care.

• Provide specialist medicines advice to GPs, nurses, allied health professionals and patients.

• Implement national and local medicines guidance, formulary recommendations and safety alerts (e.g. MHRA).

• Contribute to long term condition management, including optimisation of prescribing for conditions such as hypertension, diabetes and respiratory disease.

Medicines optimisation and governance:

• Lead on prescribing safety and quality improvement initiatives across the PCN.

• Contribute to achievement of prescribing elements of the Quality and Outcomes Framework and Enhanced Services.

• Undertake audits and data analysis to identify opportunities for improvement.

• Support the development of prescribing policies, protocols and standard operating procedures.

• Promote cost-effective, evidence-based prescribing across the network.

Multi-disciplinary working:

• Participate in multi-disciplinary team (MDT) meetings, including those focused on complex patients and care home residents.

• Support case management discussions by providing medicines expertise.

• Work closely with pharmacy technicians and support their development where appropriate.

• Contribute to the training and mentoring of junior pharmacists, students and other staff.

Professional development and supervision:

• Maintain up to date continuing professional development in line with GPhC requirements.

• Participate in peer support, supervision and regular appraisal with the Lead Clinical Pharmacist.

• Engage in learning opportunities within the PCN and wider system.

General responsibilities:

• Work across practices in Burnham on Sea, Berrow, Highbridge, Cheddar and Brent, with travel between sites as required.

• Uphold all PCN and practice policies including confidentiality, information governance, safeguarding, equality and diversity, infection prevention and control and health and safety.

• Contribute to audits, service evaluation and continuous quality improvement.

• Represent the PCN professionally in interactions with patients, staff and partner organisations.

Person Specification

Experience

Essential

• Minimum of two years experience as a pharmacist.
• Evidence of clinical medication review and managing patients with long term conditions.
• Experience of working in multi-disciplinary teams.

Desirable

• Experience in primary care or community settings.

Qualifications

Essential

• MPharm degree (or equivalent) and GPhC registration
• Independent Prescriber qualification with at least 12 months of post-prescribing experience.

Desirable

• Completion of the CPPE Primary Care Pathway.
• Postgraduate qualification in clinical pharmacy or related field.

Knowledge & Skills

Essential

• Strong knowledge of medicines optimisation and prescribing safety.
• Ability to interpret and apply national and local guidance to clinical practice.
• Excellent communication and interpersonal skills, with the ability to influence and negotiate.
• Competence in IT systems, including clinical systems and Microsoft Office.
• Ability to prioritise workload and manage competing demands
• Commitment to equality, diversity and inclusion in practice.

Other Requirements

Essential

• Full UK driving licence and access to a vehicle for work purposes
• Ability to travel routinely across Burnham on Sea, Berrow, Highbridge, Brent, Cheddar and Axbridge
• Right to work in the United Kingdom

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

North Sedgemoor PCN

Address

Axbridge & Wedmore Medical Practice

The Surgery, Houlgate Way,

Axbridge,

Somerset

BS26 2BJ

United Kingdom

Job description

Job responsibilities

Clinical:

• Undertake structured medication reviews for patients with complex polypharmacy, long term conditions and frailty.

• Prescribe safely and appropriately within scope of competence.

• Support Enhanced Health in Care Homes, including medicines reviews and participation in ward rounds.

• Reconcile medicines after hospital discharge and support safe transfer of care.

• Provide specialist medicines advice to GPs, nurses, allied health professionals and patients.

• Implement national and local medicines guidance, formulary recommendations and safety alerts (e.g. MHRA).

• Contribute to long term condition management, including optimisation of prescribing for conditions such as hypertension, diabetes and respiratory disease.

Medicines optimisation and governance:

• Lead on prescribing safety and quality improvement initiatives across the PCN.

• Contribute to achievement of prescribing elements of the Quality and Outcomes Framework and Enhanced Services.

• Undertake audits and data analysis to identify opportunities for improvement.

• Support the development of prescribing policies, protocols and standard operating procedures.

• Promote cost-effective, evidence-based prescribing across the network.

Multi-disciplinary working:

• Participate in multi-disciplinary team (MDT) meetings, including those focused on complex patients and care home residents.

• Support case management discussions by providing medicines expertise.

• Work closely with pharmacy technicians and support their development where appropriate.

• Contribute to the training and mentoring of junior pharmacists, students and other staff.

Professional development and supervision:

• Maintain up to date continuing professional development in line with GPhC requirements.

• Participate in peer support, supervision and regular appraisal with the Lead Clinical Pharmacist.

• Engage in learning opportunities within the PCN and wider system.

General responsibilities:

• Work across practices in Burnham on Sea, Berrow, Highbridge, Cheddar and Brent, with travel between sites as required.

• Uphold all PCN and practice policies including confidentiality, information governance, safeguarding, equality and diversity, infection prevention and control and health and safety.

• Contribute to audits, service evaluation and continuous quality improvement.

• Represent the PCN professionally in interactions with patients, staff and partner organisations.

Person Specification

Experience

Essential

• Minimum of two years experience as a pharmacist.
• Evidence of clinical medication review and managing patients with long term conditions.
• Experience of working in multi-disciplinary teams.

Desirable

• Experience in primary care or community settings.

Qualifications

Essential

• MPharm degree (or equivalent) and GPhC registration
• Independent Prescriber qualification with at least 12 months of post-prescribing experience.

Desirable

• Completion of the CPPE Primary Care Pathway.
• Postgraduate qualification in clinical pharmacy or related field.

Knowledge & Skills

Essential

• Strong knowledge of medicines optimisation and prescribing safety.
• Ability to interpret and apply national and local guidance to clinical practice.
• Excellent communication and interpersonal skills, with the ability to influence and negotiate.
• Competence in IT systems, including clinical systems and Microsoft Office.
• Ability to prioritise workload and manage competing demands
• Commitment to equality, diversity and inclusion in practice.

Other Requirements

Essential

• Full UK driving licence and access to a vehicle for work purposes
• Ability to travel routinely across Burnham on Sea, Berrow, Highbridge, Brent, Cheddar and Axbridge
• Right to work in the United Kingdom

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

North Sedgemoor PCN

Address

Axbridge & Wedmore Medical Practice

The Surgery, Houlgate Way,

Axbridge,

Somerset

BS26 2BJ

United Kingdom