Care Coordinator for Inequalities and Access

2 weeks ago


Taunton, United Kingdom Taunton Central Primary Care Network Full time

People experiencing the worst health inequalities include those in the following groups:

- Gypsy, Traveller and Roma groups
- homeless people and those insecurely housed
- vulnerable migrants, refugees and asylum seekers
- people in contact with the criminal justice system
- people with learning disabilities
- people with SMIs (severe mental illness)
- housebound
- care leavers
- people with a language barrier
- people with low health literacy
- people with drug and alcohol problems
- people digitally excluded with no access to the internet or broadband

Our Care Coordinator will use assertive outreach skills to engage people who are hard to reach. You will reach out to those communities who sometimes feel voiceless to give them the help and support they need. You will support patients in preparing for or in following up clinical conversations they have with PCN primary care professionals. You will be working with patients to help ensure they have the right support and to signpost to the relevant local voluntary sector organisations that can support them with their non-clinical health needs.

From the patient’s perspective, nobody is more highly valued than the care coordinator, who is their go-to person if their needs change or if something goes wrong with service delivery. Many elderly and disabled people have highly complex needs and would struggle to coordinate with all the relevant services directly. The care coordinator relieves them of this burden and ensures that there are no gaps in service provision.

Support provided directly with patients and their carers would include supporting the development of personalised plans, utilising decision aids, providing information, making appointments, coordination and navigation for people and their carers across health and care services.

**Primary Duties and Areas of Responsibility**
- Work with the PCN member practices to identify and address access barriers for those who struggle to access healthcare.
- Working with other PCN Care Coordinators, raise awareness of health promotion, screening, NHS Health Checks and LD Health checks with patients.
- Liaise with GPs and practice teams to identify individual patients who struggle to access health services and/or coordinate effectively with all relevant services.
- Act as a point of contact between GP, patients, carers and other agencies.
- Manage patient-initiated calls for help/signposting etc., ensuring patients are directed to appropriate services.
- Support patients to self-manage their care including referrals to Social Prescribing Link Workers where a patient may benefit from this service.
- Link in with and build relationships with the wider PCN team, Social Prescribers, Pharmacists, Health and Wellbeing Coaches and other clinical/non-clinical partners involved in the patient’s care.
- Holistically bring together all of a person’s identified care and support needs, and explore options to help them achieve their needs.
- 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 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 professionals.

**Primary Duties and Areas of Responsibility - Direct patient facing work**
- Holistically bring together all of a person’s identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
- Support patients to utilise decision aids in preparation for a shared decision-making conversation.
- 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.
- 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 Patient Activation Measure.
- 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.
- Explore and assist people to access personal health budgets where appropriate.

**Communication and collaborative working relationships**
- Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs.
- Liaise with other stakeholders as needed for the collective benefit of patients including but not limited to Patient’s GP, Nurses, other practice staff and other healthcare professio


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