Care Coordinator
2 weeks ago
Job responsibilities Identify patients who will benefit from discussion at the MDT meetings (as per the agreed identification criteria supported by a variety of risk stratification tools), together with input from the E4 PCN clinical lead and stakeholders from NELFT, the acute Trust and Social Care Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT meetings under the direction of the lead clinician for the E4 PCN.
Maintain efficient filing systems, clerical and office systems, providing administrative support to the core members of the MDT To actively track patients progress through the patient pathway to ensure that care is carried out in a timely fashion on daily basis and follows escalation and tracking process and liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms Work closely with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated and of the patients care plan, without requiring a further referral from the GP.
Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical EMIS or System One, within the required time frame.
Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations communications & patient notes.
General co-ordination and actioning of MDT outcomes and recording of progress and ensure all patient notes are updated to reflect any changes, including details on plans.
Maintain standard operating procedures and processes for administrative and clinical systems Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and support the meetings.
Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance and followed up appropriately.
Ensure that meeting actions are recorded and co-ordinate the administration functions of the multidisciplinary team meetings, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.
Network and develop strong relationships with all levels of the NHSs key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector Be a contact point within the E4 PCN for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders To ensure patients diagnoses, investigations, and management and treatment plans are completed and added to the patients notes/electronic clinical reporting database in a timely fashion.
To be proficient in using Microsoft office packages and other identified IT systems including EMIS and System One Other duties Work within the policies of the scheme and Practices.
Promote client involvement in the management of the service. Participate in regular appraisals Attend training and development activities as identified and participate in meetings as required.Maintain administration systems and workspace used in a clean and tidy condition.
Maintain a good working knowledge of Health and Safety and Information Governance procedures and fire precautions, and operate the correct procedures and participate in policy development and data collection where appropriate.
Work flexibly to meet the needs of patients and be able to adapt to change To undertake any other duties appropriate to the grade and purpose of the job that is required from the PCN.
Complete all mandatory training within specified requirement and time frame.
Patient Services To provide services to patients via clinics in the PCN, domiciliary visits and in residential and nursing homes, and to deliver care plans that improve the quality of patient care.
To help plan, develop and support the introduction of new working processes within the PCN to optimise the patient uptake.
Communication The post-holder should recognize the importance of effective communication within the team and will strive to: Communicate effectively with other team members.
Communicate effectively with patients and carers Recognise peoples needs for alternative methods of communication and respond accordingly.-
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