Care Co-ordinator
1 week ago
Primary Duties and Areas of Responsibility Multi-Disciplinary Teams Overall responsibility for arranging the weekly PCN led MDT meetings (including the weekly virtual Care Home(s) MDT) and the smooth running of integrated care within the team setting.
A key role of the Care Coordinator will be to schedule the weekly MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
Take minutes 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 IdentificationUtilise 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 weekly 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 Manage a caseload of patients identified through the MDT 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 wellbeing, 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 wellbeing and increase their activation level.
Explore and assist people to access personal health budgets where appropriate. Communication and collaborative working relationships Demonstrates ability to work as a member of a team.Is able to 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 the all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT Acting as a point of contact for residents, families, carers and professionals who visit the care home, such as MDT members and in-reach specialists.
Provide background information about individuals for the weekly 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 wellbeing 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 in order to maintain competency including mandatory training To contribute to, and work within a safe working environment.
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Care Co-ordinator
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