Care Coordinator

3 weeks ago

London, United Kingdom Battersea Primary Care Network Full time

Battersea Primary Care Network comprises 5 GP surgeries with a combined population of approximately 55,000 patients. Our practices are close geographically and we work closely together. We employ new roles health care staff to improve health care services for patients and to support the clinical and administrative work of each practice. Our first Care Co-ordinator started working at Battersea PCN in March 2021. The role has been very successful and we are now looking to expand our team.

**Job summary**: Care coordinators provide extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They work closely with GPs, nurses and other primary care professionals within the PCN to identify and manage a caseload of patients, making sure that appropriate support is made available to them, and ensuring that their changing needs are addressed. Their areas of focus will reflect the Comprehensive Model for Personalised Care, and will depend on local priorities and health inequalities that have been identified by the PCN.

**Place of work**: The Care coordinator may be required to work from any of the PCN practice sites as needed, but each care co-ordinator in our team will have a main base in one or two of our practices.

**Principal Duties**:
**These may vary according to the current needs and priorities of the GP practices/PCN teams but may include any or all of the following**:
1. Working proactively with a caseload of identified patients to support their personalised care requirements, (for example this might include patients with complex care needs, learning difficulties or dementia or families requiring support):

- Providing 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 roles. This might include answering their queries, supporting them to make and get to appointments and co-ordinating their medical care when required
- Sign-posting patients and carers to appropriate support services
- Working with clinicians to ensure all the contractual requirements for patients with complex care needs are met
- Supporting the co-ordination and administration of MDT meetings including obtaining information required for meetings and co-ordinating actions identified during these meetings
- Ensure that people have good quality information to help them make choices about their care, and assist people to have shared decision-making conversations with healthcare teams
- Bring together a person’s identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with person centred service plan (PCSP) best practice

2. Supporting and promoting preventative healthcare by proactively contacting and having discussions with people eligible for public health programmes such as immunisation and cancer screening programmes. The aim is to increase uptake, particularly in hard to reach and vulnerable communities.

3. Setting up and running clinical searches in order to monitor and focus care of target groups

4. Provide organisational and operation support for public health initiatives being delivered by the PCN, such as Covid vaccination clinics

**Other responsibilities**
- To work at all times within the requirements of GDPR
- Maintain accurate clinical records at all times
- To participate in educational events as advised by the Practice
- To attend various Practice meetings as requested
- Any other tasks that may be required by the practice from time to time

**Clinical System / Medical Records**
- Ensure total familiarity with the clinical system;
- Book appointments and recalls ensuring sufficient information is recorded;
- Code and extract data from clinical correspondence and input into EMIS Electronic Patient Record
- Run searches and produce reports as required with the support of practice IT teams
- Ensure correspondence, reports, results etc. are dealt with in a timely manner as per practice protocol
- Shared responsibility for target group disease register with clinical teams

**Telephone System**
- Receive and make calls as required answering any queries that arise
- Divert calls and take messages as appropriate ensuring accuracy

**Confidentiality**:

- In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately
- In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. They may also have access to information relating to the Practice and PCN as a business organis

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