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Care Coordinator
3 months ago
Care Co-ordinator
Responsible To:
Clinical Director, Vale of Evesham PCN
Hours:37.5 per week
Salary:
Band 4
Location:
Vale Of Evesham PCN (New Barn Close Surgery)
Overall Purpose of Job:
We are seeking a Care Co-ordinator who will play a key co-ordinating role in Vale of Evesham PCN.
A care co-ordinator provides extra time, capacity and expertise to make sure that appropriate support is made available to residents of care homes and ensure that their needs are addressed.
They will help residents and their families to understand, manage and utilise personal care and support plans and contribute to increasing the number of patients with personal health budgets in place.
The care co-ordinator will work closely with Primary Care Network (PCN) and GP Practices to ensure patients receive coordinated care, which is responsive to their needs and designed in co-operation with patients, carers, and all supporting services.
Tackling health inequalities is a major focus for the PCN and this role will ensure that this key priority is embedded within all work carried out by the Care Coordinator team, who will be providing much needed advice and guidance to a diverse population of patients.
This role aims to give patients and their carers more control over their own health and care, achieve greater collaboration between GPs and their teams and community services, strengthen joint working with local partners, and improve health outcomes and tackle health inequalities.
The Care Coordinator will work as an integral part of the multi-disciplinary team supporting patients with multiple and complex needs and their carers to take an active and informed role within their own health care and wellbeing.
They will work closely with care home staff and other services to ensure the provision of seamless and integrated support.
Main Responsibilities are to:
With the use of Clinical Systems and engagement with PCNs and Practices, actively identify a caseload of patients who are in need of a care package at a designated surgery
Work directly with patients, their carers and advocates in line with best practice, to develop a holistic personalised care and support plan that brings together all the patients identified care and support needs and reflects what matters most to them.
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.
Assist patients and their carers to access support or interventions that improve their health and well being and increase their knowledge, skills and confidence.
Provide co-ordination and navigation for people and their carers across health and care services, Social Prescribing Link Workers, Lifestyle Advisors and other primary care professionals.
Identify, report and action any issues of concern relating to safeguarding and quality of care arising from working with patients and referring onwards as appropriate.
Care Co-ordination:
Care Planning:
- Record, action and follow up referrals and care packages agreed for all patients within the PCN, especially those discussed at internal MDT meetings.
- Working with clinicians within your allocated practice, service users/patients, their families and carers, codesign and deliver care plans and ensure that the actions set out are being followedup and evaluated and are coordinated around the needs of the service user.
- Ensure that all individual care plans remain up to date, that they are evaluated and revised as necessary and that record keeping is completed as appropriate.
Identifying vulnerable patients that require an integrated care team approach:
- Ensure that individual care plans are revised following key events such as hospital admission or discharge, significant improvements or deterioration of their condition or service user/patient/carer concerns.
- Liaise directly with other teams within the health and care sector e.g Worcestershire Acute Hospitals Trust, Worcestershire Health and Care Trust, Worcestershire County behalf of the clinical team to ensure that actions are followed up.
- Identify networks of local statutory and voluntary and community support services that could be deployed to assist individuals to achieve optimum health and wellbeing. Develop positive relationships in order to coordinate effective and responsive pa
