Care Cooordinator

About Personalised Care

Personalised care represents a new relationship between people, professionals and the health and care system. It provides a positive shift in power and decision making that enables people to have a voice, to be heard and be connected to each other and their communities.

This approach learns from the experience of social care in embedding personalised care in everyday practice, which has enabled people to take control over the funding for their care. It also builds on pockets of progress made in health.

Critically, personalised care takes a whole-system approach, integrating services around the person including health, social care, public health and wider services. It provides an all-age approach from maternity and childhood right through to end of life, encompassing both mental and physical health and recognises the role and voice of carers. It recognises the contribution of communities and the voluntary and community sector to support people and build resilience.

Overview

Care co-ordinators are personalised care roles. They focus on what matters to individuals and support people from diverse backgrounds, including those with a range of conditions and disabilities. They co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They are skilled in personalised conversations, assessing people’s needs, facilitating joint working, ensuring the effective flow of information, monitoring needs and responding to change.

Care co-ordinators work in different settings across health and care, including but not limited to primary care, hospitals and secondary care services, end of life care, children and family services, community health services and care homes. They offer significant benefits to individuals they support and the health and care system, for example freeing up clinical capacity and reducing the likelihood of the need for acute or crisis care. (NHSE, 2023)

Role Responsibilities

• Proactively identify and work with a cohorts of people, appropriate to the population needs of the PCN e.g. cancer care, Learning Disability and Autism, Dementia, Care Homes etc.
• Work with people individually, building trusting relationships, listening closely and working with them to develop a personalised care and support plan, based on what matters to the person.
• Help patients in avoiding unnecessary appointments, procedures, and tests, and to feel more empowered and actively engaged in their treatment
• Create more 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
• Identifying and support high-risk patient populations before they incur costlier medical intervention
• Review people’s identified needs and help to connect them to the services and support they require, whether within the practice or elsewhere.
• Support to create a richer picture on practice population health needs and risks; by gaining information about patients’ treatment histories, medication adherence, new symptoms, and management of chronic conditions
• Support the coordination and delivery of multidisciplinary teams within PCNs.

Boundaries of Care Co-ordinators:

Care co-ordinators should focus on what is important to the patient and not be drawn into taking a prescriptive or directive approach. In primary care their role is non-clinical.

They need to be confident in their area of expertise and aware of the boundaries of their role. Boundaries are important in safely supporting people and managing the expectations of the individual and other teams involved in their care.

Training and Development

Supervision Requirements

Supervision is a process of professional learning and development that enables individuals to reflect on and develop their knowledge, skills and competence, through regular support from another professional.

Supervision can have different forms and functions and a number of terms are used to describe these. For this guidance we use the below terms and define them as follows:

• Clinic/practice supervision: day-to-day support provided by a named/duty senior/more experienced clinician for issues arising in the practice.
• Clinical/professional supervision: regular support from a named senior/experienced clinician/practitioner to promote high clinical standards and develop professional expertise.
• Educational supervision: supports learning and enables learners to achieve proficiency.

Care Co-Ordinator Supervision:

Good supervision arrangements for care co-ordinators are crucial. Supervision is key in terms of supporting care co-ordinators to excel in their role and in supporting their ongoing CPD, especially those new to the role who are less experienced.

Organisations that employ care co-ordinators should have appropriate supervision arrangements in place, including a named first point of contact for general advice and support. Supervisors should be experienced members of staff with a good understanding of the role of a care co-ordinator and ideally an understanding of advanced communication skills. It is recommended that supervision should take place on a minimum of a monthly basis (for full time staff) and this could be provided by one or more named individuals. New, less experienced care co-ordinators may need more frequent supervision in the first six months as they learn about the role and the setting they are working in.

It is recommended that Care Co-ordinators have access to appropriate supervision and an appropriate named individual in the PCN with the relevant competencies, as described in the career framework, e.g. GP, senior clinician/professional including advanced Practitioner.

Recommended minimum frequency of a 1-hour supervision meeting is monthly (NHSE Supervision guidance, 2023)

Supervision Guidance for primary care network multidisciplinary teams (NHSE, 2023)

NHS England » Workforce development framework for health and wellbeing coaches