Care Co-ordinator

6 months ago

Kettering, United Kingdom Burton Latimer Medical Centre Full time

Key Responsibilities Support National Screening Programmes, Quality and Outcomes Framework and Directed Enhanced Services 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 Patient Activation Measure (PAM). 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, health and wellbeing coaches, 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, 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 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. Key Tasks 1. Enable Access to Personalised Care and Support a.

Take referrals for individuals or proactively identify people who could benefit from support through care coordination. b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs. c.

Support people to develop and implement personalised care and support plans. d. Review and update personalised care and support plans at regular intervals. e.

Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes. f. Where a personal health budget is an option, to work with the person and the local CCG team to provide advice and support as appropriate. 2.

Coordinate and Integrate Care a. Help people transition seamlessly between services and support them to navigate through the health and care system. b. Refer onwards to social prescribing link workers and health and wellbeing coaches where required.

c. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported. d. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate.

e. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. 3. Data and Information Capture a.

Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation. b. Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing. c.

Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives. d. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. Professional Development 1.

Work with your line manager to identify and undertake continual personal and professional development, taking an active part in reviewing and developing the role and its responsibilities, providing evidence of learning activity as required. 2. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. 3.

Work with your line manager to access regular clinical supervision, to enable you to deal effectively with the difficult issues specific patients present. 4. Undertake mandatory and departmen

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