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Care Coordinator
3 months ago
Be the co-ordinator of reactive (urgent care for those in need) and proactive (planned care to support people to live independently) services for patients.
Ensuring that healthcare professionals focus their limited resources on those in most need, co-ordinating the right intervention for each patient, ensuring consistent records are kept of care plans and interventions and ensuring that records are shared appropriately with all health and social care professionals involved in caring for each patient.
Organise and facilitate multi-disciplinary meetings between members of the wider healthcare team to discuss, update and share care plans as appropriate.
Keep accurate records of decisions made about individual patients and follow up where necessary, ensuring health professionals act on the decisions.
Co-ordinate collection of regular data returns to the ICB and other agencies as appropriate.Contact patients where appropriate to advise about health issues or provide social prescribing advice and guidance.
Bring together all of a persons identified care and support needs, and explore their options to meet these into a single personalised care and support plan.
Co-ordinate care between GPs, other practice based clinical team members, community matrons, district nurses, palliative care nurses, community therapists, other community staff, social care, voluntary sector organisations and wider health and social care services.
Work closely with the GPs and other primary care professionals to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision making conversation.
Provide 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.
Work with clinicians to minimise the number, and maximise the effectiveness, of appointments and home visits.Assist with virtual weekly ward rounds Pro-actively monitor the effectiveness of appointments and the reasons for non-attendance Send out and obtain information, especially to help empower patients to optimise self-care Promptly refer any patient concerns to a clinician, and act on responses Respond to enquiries and requests from patients, their carers and external health and social agencies Help to ensure patient medical conditions are being well managed, and share care plans with other clinicians or third parties where relevant Monitor patient information relating to (for example), A&E attendance, hospital admission and medications Manage and maintain registers of Long Term Condition patients and Practices clinical systems, ensuring IT security and IG compliance at all times and adding clinical codes to medical records to assist with reporting Undertake works in areas, such as Learning Disability, Palliative Care, Mental Health and Cervical Screening.
This will include:
Participating in local training and meetings (including taking minutes); maintaining registers; coordinating reviews; booking home visits; arranging tests; ensuring appropriate methods of communication; overseeing clinics.
Keep up to date with Safeguarding by:
participating in training and meetings; maintaining registers; liaising with safeguarding lead; and ensuring that reports are completed in time Support the Clinical Pharmacy team in implementing the in-house medication monitoring system.
This will involve identifying patients that require monitoring and arranging appropriate appointments and follow up. To maintain relevant databases to support this work.
Support the coordination of appointments for the Pharmacy Team to ensure achievement of Impact and Investment Fund indicators including Structured Medication Reviews and QOF related reviews as agreed with the GP Practice.
Adhere to all practice policies, procedures and protocols, ensuring compliance with CQC, Health & Safety, Confidentiality, Data Protection and Employment Legislation.2.
Be flexible during sickness/holidays of other team members and provide cover as required.