Care Co-ordinator

3 weeks ago

Leatherhead, United Kingdom Epsom and St Helier University Hospitals NHS Trust Full time

Surrey Downs Health & Care

An opportunity has arisen within Leatherhead PCN to join our fast-growing team. If you can work autonomously, have good communication skills and want to make a difference this is the role for you.

This is an exciting and innovative role which will involve working alongside community GPs, paramedics, pharmacists, district nurses, adult social care, voluntary organisations and community matrons to support the delivery of proactive healthcare and support to people living with frailty, multiple long-term conditions and/or complex needs to help them stay independent and healthy for as long as possible at home.

Leatherhead PCNprovides local proactive coordinated health and care support to the population of65,000 patients across the 6 Leatherhead based practices.

We are committed to keeping people well at home andin community settingsandsupport people to live independently.

We recognise the importance of preventative measures, working closely with GP’s, Frailty teams in recently set up MDT’s. We provide Rapid Response visits and support in care homes. We provide innovative, flexible service delivery, managing increased demand and more complex care needs.

We are committed to your ongoing professional development and offer a structured training programme to support the requirements set out within the national Care Co-ordinator job profile.

The post holder will support the provision of the highest quality patient care through dedicated administrative and clerical support facilitating multi-disciplinary care provided by other professionals.

The Community Multi-disciplinary Team delivers integrated care with a key aim to reduce hospital admissions, readmissions and maintain patient care within the community or within the patient’s home.

The post holder will facilitate the delivery of high levels of patient care and will ensure that patients and clinicians have a good experience by being an accessible, customer focused and knowledgeable point of contact.

With a focus on collaborative working in line with the NHS long term plan with the Ageing Well programme. Alongside our local GP practices and using population health data to improve, refine and to proactively anticipate care needs. This also includes support work with our local care homes as a liaison to further improve care.

Surrey Downs Health and Care (SDHC) deliver care closer to people’s own communities through our Primary Care Networks and our innovative partnership of local NHS organisations.

Surrey Downs Health and Care has a track record of providing person centric care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes:

- The three GP federations GP Health Partners, Dorking Health Care and Surrey Medical Network representing practices that operate in the Surrey Downs area
- CSH Surrey
- Epsom and St Helier’s University Hospitals NHS Trust
- Surrey Council County

Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us.

It’s on those grounds that the Surrey Downs Health and Care was formed - we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before.

In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.
- Work with people, their families and carers to improve their understanding of the patients’ 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.
- Provide co-ordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
- Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, including frailty, dementia and high blood pressure and where appropriate, refer back to other health professionals within the PCN.
- Support the co-ordination and delivery of multidisciplinary teams with the PCN.
- 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 decision-making conver

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