Care Coordinator

3 months ago

Scarborough, United Kingdom Scarborough Medical Group Full time

KEY RESPONSIBILITIES Please see the attached job description and person specification for further details. 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. Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the ONS 4 personal wellbeing score, where this is relevant.

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their Activation level. 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, other primary care professionals and health and social care colleagues; 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, and where appropriate, refer back to other health professionals within the PCN.

Support the coordination and delivery of multidisciplinary teams with the PCN. Raise awareness of how to identify dementia patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations. Explore and assist people to access a personal health budget where appropriate. Work with people, their families, carers and healthcare team members to encourage effective help seeking behaviours; Support the PCN in developing communication channels between GPs, people and their families and carers and other agencies; Identify unpaid carers and help them access services to support them; Conduct follow-ups on communications from out of hospital and in-patient services; Maintain records of referrals and interventions to enable monitoring and evaluation of the service; Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the individuals circumstances; Contribute to risk and impact assessments, monitoring and evaluations of the service; Work with commissioners, integrated locality teams and other agencies to support and further develop the role.

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