Care Coordinator: Focus Is Patients with Complex

2 weeks ago

London, Greater London, United Kingdom Francis Grove Surgery Full time
The care co-ordinator will work with the practice team to co-ordinate appointments for specific cohorts of patients.

They will also work with higher risk or vulnerable cohort's patients supporting and encouraging them to access medical and non-medical services and attend appointments.

They will be based in an individual practice and work closely with the whole team there as well as the PCN on occasion.


They will have the opportunity to work beyond the PCN, looking at patient non-medical needs whilst connecting with additional organisations as necessary to prevent avoidable hospital admissions.

Liaison with other medical professionals, carers, social prescribing link workers, council, voluntary services and community organisations, ensuring health and care planning is timely, efficient and patient-centred.

They will also lead on various vaccination campaigns (including COVID vaccination) to ensure the highest uptake of the vaccines.

The PCN Care Co-ordinators will:

  • Work with colleagues within the GP practice and PCN to identify and manage appointments for cohorts of patients who are vulnerable, higher risk, or that may have longterm conditions for example those with Dementia, Mental Health, Asthma, Diabetes/prediabetes, pts with as yet undiagnosed conditions and other complex needs.
  • Liaising with other health professionals as required, to deliver personalised care
  • Ensure patients are called in when blood tests are due as a result of being on high risk medications or due to their long term conditions.
  • Be the first point of contact for the complex cohorts of patients
  • Proactively support 'call and recall' processes, encouraging and supporting patients to attend
  • Support with and undertake the call and recall for vaccination campaigns to ensure the highest possible uptake e.g. COVID, Flu.
  • Work closely with the PCN social prescribing link worker and Mental Health Practitioner
  • Work proactively with the PCN pharmacists to support the medication review process and and regular drug monitoring requirements
  • Coordinate the booking the PCN paramedic appointments for home visits and practice appointments, ensuring patients who need health reviews are seen in a timely manner and the paramedic's time is fully utilised.
  • Ensure Mental Health Practitioner's clinics are utilised effectively and patients whom require reviews or support are attending their appointments,
  • Review appointment book daily and notify GP's of any outstanding checks that patients may need.
  • Proactively support multidisciplinary, practice clinical or safeguarding team meetings (dates, agenda, papers) when required.
  • Ensure all coordinated activity is documented and coded accurately
  • Champion the use of digital communication platforms
  • Build relationships with our community service providers
  • Raise awareness within the PCN of shared
- decision making and decision support tools

  • Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decisionmaking conversations
- 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;
- 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

  • Assist with answering calls and booking appointments for the first hour in the mornings. 8am start.
  • Support the reception team with cover the reception desk when they are short staffed.

PROFESSIONAL INTEGRITY
- the PCN Care Coordinator will be supported by other staff within the admin and management team, as well as by GP's or Nurses to discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health).

  • The Care Coordinator will be expected to undertake developmental training to support the evolution of this new role.

Job Types:
Full-time, Permanent

Pay:
£23,300.00 per year

Benefits:

  • Company pension
  • Employee discount

Schedule:

  • Monday to Friday

Ability to commute/relocate:

  • LONDON: reliably commute or plan to relocate before starting work (required)

Work authorisation:

  • United Kingdom (required)

Work Location:
In person

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