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Patient Care Coordinator Administrator- Dashwood
3 months ago
Primary Duties and Areas of Responsibility utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
serve as the contact point, advocate and informational resource for patients, care teams, family /caregivers and community resources, responding with empathy and respect and signposting where appropriate.
ensure regular and consistent communication with care homes regarding patient progress. support patients to utilise decision aids in preparation for a shared decision-making conversation.acknowledge patients rights on confidential issues; maintain patient confidentiality at all times.
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.
visit patients in community, home or care home setting to assess and discuss their care needs involving carers as appropriate.
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 with the identification of high risk patients and keep a register of the teams workload.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.
undertake visits or arrange appointments at their Practice for patients on the PCNs case load or otherwise as directed by the Duty Doctor following identification of urgent and non-urgent clinical need to assess, diagnose, treat, prescribe and refer appropriately according to the patients health needs and acting within the PCNs clinical skill set.
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.
refer through to the appropriate member of the team, and/or make referrals on behalf of the team.
support the coordination and delivery of multidisciplinary teams (MDTs) within the PCN, to include management of the team diaries and arrangement/planning of team meetings and producing reports as requested.
