Care Coordinator

Care Coordinator

Questions?

If you have any questions relating to health and wellbeing coaches, please send your queries to [email protected]

Care Coordinators

"Care Coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care
services. "

Source: HEE's Care Coordinator Role Overview

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What are they?

What benefits can they bring?

What is their scope of practice?

Is funding available for them?

Any case studies?

What characteristics, training / qualifications, and competencies should they have?

Are there any requirements to receive ARRS funding?

Any example job descriptions?

Any sample interview questions?

What clinical supervision do they need?

What should practice induction include?

What ongoing support is available for care coordinators?

What are care coordinators?

Care coordinators work as part of the general practice multidisciplinary team (MDT) to identify people in need of proactive support; this could mean, as a examples, people living with frailty or with multiple long-term physical and mental health conditions. Care coordinators will work with these patients on a 1-2-1 basis, building trusting relationships, listening closely to what matters to them, and helping them to develop a personalised care plan.

As part of this work, care coordinators will review people’s needs and help to connect them with the services and support they require, whether that’s within the practice or elsewhere – for example, community and hospital-based services. They may support people in preparing for or following up clinical conversations they have with healthcare professionals, to enable them to be actively involved in managing their care and supported to make choices that are right for them.

They will work closely with social prescribing link workers and health and wellbeing coaches, referring people to them and also receiving referrals in return.

For more information:

NHSE / I Welcome Pack for Care Coordinators

Provided by NHS England & NHS Improvement (NHSE / I), this document serves as a welcome pack for care coordinators starting employment in a primary care network.

To read it, please click here.

What benefits can they bring?

Surrey Training Hub have helpfully condensed the benefits provided by care coordinators, as follows:

  • Care coordinators are the patient’s go-to person if their needs change or if something goes wrong with service delivery: the care coordinator ensures that there are no gaps in the patient’s service provision, as many elderly and disabled people with highly complex needs struggle to coordinate with all the relevant services directly on their own
  • Care coordinators help improve patient education and understanding, and overall better health outcomes
  • They can help patients in avoiding unnecessary appointments, procedures, and tests, and to feel more empowered and actively engaged in their treatment
  • A 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
  • By identifying high-risk patient populations before they incur costlier medical intervention, employers can begin to reduce both practice expenses and total NHS costs
  • Employers can gain access to additional data that can reveal practice population health levels and risks; care coordinators glean information about patients’ treatment histories, medication adherence, new symptoms, and management of chronic conditions

For more information:

Surrey Training Hub Role Overivew

This is Surrey Training Hub’s overview for the care coordinator role.

To read it, please click here.

What is their scope of practice?

According to Health Education England (HEE), a care coordinator should undertake the following activities, as part of their role:

  • Proactively identifying and working with a cohort of people to support their personalised care requirements
  • Supporting people to use decision aids in preparation for a shared decision making conversation
  • Bringing together a person’s identified care and support needs and exploring their options to meet these into a single personalised care and support plan, in line with person-centred service plan (PCSP) best practice
  • Helping people to manage their need, answering their queries, and supporting them to make appointments
  • Supporting people to take up training and employment, and to access appropriate benefits where eligible
  • Raising awareness of shared decision making and decision support tools and assisting people to be more prepared to have a shared decision making conversation
  • Ensuring that people are well-informed, to help them make choices about their care
  • Supporting people to understand their level of knowledge, skills, and confidence (Patient Activation Measure*) when engaging with their health and wellbeing, including through use of the patient activation measure
  • Assisting people to access self-management education courses, peer support, or interventions that support them in their health and wellbeing
  • Exploring and assist people to access personal health budgets where appropriate
  • Providing coordination 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
  • Supporting the coordination and delivery of multidisciplinary teams (MDTs) within PCNs

For more information:

HEE Care Coordinator Role Overview

Provided by Health Education England (HEE), this page offers a succinct look at the education and training requirements, skills and competencies, and work activities of care coordinators.

To read it, please click here.

Is funding available for them?

As care coordinators are included on the additional roles reimbursement scheme (ARRS), funding is available for them; from April 2020, this role can be reimbursed at 100% of actual salary plus defined on-costs, up to the maximum reimbursable amount of £29,135 over 12 months.

For more information:

HEE Care Coordinator Role Overview

Provided by Health Education England (HEE), this page offers a succinct look at the education and training requirements, skills and competencies, and work activities of care coordinators.

To read it, please click here.

Any case studies?

Neither Health Education England (HEE) nor NHS England & Improvement (NHSE / I) presently have any case studies on care coordinators. Please stand by for an update.

What characteristics, training / qualifications, and competencies should they have?

Please find information on what you should look out for when employing a care coordinator below:

Training and Qualifications

Health Education England (HEE) state in their care coordinator role overview that:

“Care Coordinators require a strong foundation in enabling and communication skills as set out in the core curriculum for personalised care. These can be achieved via a two day health coaching skills course, as set out here.”

“Care coordinators should also access statuary and mandatory training, including but not limited to:

  • Principles of information governance, accountability and clinical governance
  • Maintenance of accurate and relevant records of agreed care and support needs
  • Identify when it is appropriate to share information with carers and do so
  • The professional and legal aspects of consent, capacity, and safeguarding

To read HEE’s role overview, please click here.

Essex Primary Care Careers also suggest that, while the specifics may vary based on the exact post, care coordinators should have the following:

  • Diploma / HNC (e.g., in social work, occupational therapy, mental health) and / or NVQ Level 3 Business Admin
  • ECDL or equivalent
  • Completed Welfare Rights Training
  • Strong IT and administration skills, ideally including experience in the use of databases
  • Relevant experience of, as examples, working with healthcare professionals, social care or as part of a multi-disciplinary team within general practice, to achieve improved patient health outcomes, may be advantageous
  • Experience of the delivery of personalised care to a range of different patients
  • Knowledge of the types of care and support needs and how to access support and services for patients

For more information, please click here to read Essex Primary Care Careers’ page on care coordinators.

Skills and competencies

Health Education England (HEE) advocates that care coordinators should have the following skills and competencies:

  • Active and empathic listening
  • Effective questioning
  • Building trust and rapport
  • Shared agenda setting
  • Collaborative goal setting
  • Shared follow-up planning
  • Using simple health literate communication techniques such as teach-back
  • Structuring conversations using a coaching approach
  • 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

For more information, please click here to read HEE’s role overview.

Any example job descriptions?

Neither Health Education England (HEE) nor NHS England & Improvement (NHSE / I) presently have any template job descriptions for care coordinators. Please stand by for an update.

Any sample interview questions?

Neither Health Education England (HEE) nor NHS England & Improvement (NHSE / I) presently have any sample interview questions for care coordinators. Please stand by for an update.

Are there any requirements to receive ARRS funding?

As noted under ‘Is funding available for them?‘, care coordinators can be reimbursed via the Additional Roles Reimbursement Scheme (ARRS). However, to be eligible for this funding, there are requirements that must be adhered to.

For instance, as stated in Annex B of the Network Contract Directed Enhanced Service contract specification 2021 / 22:

  • B5.2. Where a PCN employs or engages one or more Care Coordinators under the Additional Roles Reimbursement Scheme, the PCN must ensure that each Care Coordinator has the following key responsibilities, in delivering health services:
    • utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care;
    • support patients to utilise decision aids in preparation for a shared decision-making conversation;
    • holistically bring together all of a person’s 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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health;
    • support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers;
    • assist people to access self-management education courses, peer support or interventions that support them to take more control of their health and wellbeing;
    • explore and assist people to access personal health budgets where appropriate;
    • provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals;
    • and support the coordination and delivery of MDTs within the PCN.

For more information:

Network Contract DES specification 2021 / 22

Provided by NHS England & Improvement (NHSE / I), this document outlines the Network Contract Directed Enhanced Service (DES) for 2021 / 22.

To read it, please click here.

What clinical supervision do they need?

Neither Health Education England (HEE)NHS England & Improvement (NHSE / I), nor the Personalised Care Institute have provided formal guidelines regarding what clinical supervision care coordinators require in primary care.

Please stand by for an update.

What should practice induction include?

Neither Health Education England (HEE)NHS England & Improvement (NHSE / I), nor the Personalised Care Institute have provided formal guidelines regarding what practice induction should look like for care coordinators.

Please stand by for an update.

What ongoing support is available for care coordinators?

NHS England & Improvement (NHSE / I) have, in their care coordinator welcome pack, compiled a list of available support structures and mechanisms — including an online learning community, accessible by contacting:

[email protected]

NHSE / I Services

Included in their welcome pack for care coordinatorsNHS England & Improvement (NHSE / I) have compiled a list of ongoing support and resources, including:

  • Online care coordinator learning
  • Online collaboration
  • Learning, developmental, and peer support
  • Supported self-management mentors

To read it, please click here.

Personalised Care Institute

The Personalised Care Institute has a range of FREE training, resources, and podcasts available for care coordinators.

This includes training covering:

  • Core Personalised Care Skills — providing a holistic view of health and care, highlighting the benefits of personalised care, and demonstrating how it improves both health outcomes and patient / clinician satisfaction
  • Shared Decision Making
  • Personalised Care and Support Planning

The Personalised Care Institute also offers a two-day health coaching course, which allows attendees to discover and develop health coaching mindsets and skills tailored to activation. Feedback suggests that this training is experiential, authentic and immediately impactful.

To find out more, please visit their site here.

Training Hub Personalised Care Lead

The Training Hub’s Personalised Care Lead, Dr. Sarah Ballisat, can answer any queries you may have around this personalised care role and provide signposts to additional resources and specific individuals working in this area.

To contact Dr. Ballisat, please click here.

Literature
HEE Care Coordinator Role Overview

Provided by Health Education England (HEE), this page offers a succinct look at the education and training requirements, skills and competencies, and work activities of care coordinators.

To read it, please click here.

Network Contract DES specification 2021 / 22

Provided by NHS England & Improvement (NHSE / I), this document outlines the Network Contract Directed Enhanced Service (DES) for 2021 / 22.

To read it, please click here.

NHSE / I Welcome Pack for Care Coordinators

Provided by NHS England & NHS Improvement (NHSE / I), this document serves as a welcome pack for care coordinators starting employment in a primary care network.

To read it, please click here.

Surrey Training Hub Role Overivew

This is Surrey Training Hub’s overview for the care coordinator role.

To read it, please click here.

A / V resources

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