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Care Coordinator
3 months ago
Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time.
They can support people to become more active in their own health and care and are skilled in assessing people's changing needs.
Care co-ordinators are effective in bringing together multidisciplinary teams to support people's complex health and care needs.
They can be an effective intervention in supporting people to stay well particularly those with long term conditions, multiple long-term conditions, and people living with or at risk of frailty.
Working closely with GPs, Community Services, Care Homes and Practice Teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to patients and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
Enhanced Health at Home.
Key Responsibilities:
Work with people, their families, and carers to improve their understanding of the patient's condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes
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 understand their level of knowledge, skills, and confidence, when engaging with their health and wellbeing
Work as part of the multidisciplinary team, building relationships with staff in GP practices within the PCN, care homes & other organisations.
Within South Sefton PCN our aims are to:
Improve resilience in General Practice
Build a stronger and more sustainable general practice service across the Primary Care Network footprint
Facilitate collaborative working between all Primary Care Network practices
Engage with local health and care providers to develop place-based care to assist in the transformation of local services to improve the health and wellbeing of the Primary Care Network population
Work with Patient Participation Groups to improved patient access, experience and quality
Reach out to strengthen and develop working relationships with non-NHS community groups
Develop signposting with Primary Care Network practices to streamline the patient journey to enhance more achievable and sustainable outcomes
Further develop digital technology as a primary resource for practices and patients
Work in collaboration with the local GP Federation to build and strengthen relationships
As Care Coordinator your key responsibilities will include, but not be limited to:
Multidisciplinary Team (MDT)
- Arrange the EHAH led Huddles/MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified,
circulate as required.
- Consult with all members of the MDT to ensure its effective function.
- Work closely within the PCN roles, Community Services, Community Matron, MDT and with GP practices within the PCN to ensure that
sharing agreements.
- Work as part of the MDT and wider PCN / Care Community to achieve its ICP (integrated care provider) directed objectives.
- As part of the PCN MDT, build relationships with staff in each GP Practice within the PCN, attending practice meetings as required providing information and feedback on care coordination priorities.
- Consult directly with Community services, Acute Trust Ward Managers, Social Care, Practice staff and other key providers to identify
- Refer patients to local services as required utilising providers referral processes.
- Using clinical systems and data analysis to ensure a proactive approach to identifying patients that would benefit from review.
- Alerting, referring or liaising with the relevant Service, Community Matron, professionals, family, and other services as required.
- Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision making conversation.
- Work with patients, Carers, and professionals to deliver personalised care and support planning for patients.
- Help people to manage their needs through answering queries, making, and managing appointments and ensure that patients have excellent quality information to help them make choices about their care.
- Support people to understand their lev
