Clinical Care Coordinator

4 months ago

Lytham, United Kingdom Lytham St Anne’s Primary Care Network Full time

Key responsibilities Complete bloods and baseline observations including urinalysis to support with chronic disease management reviews and deteriorating residents Help care homes and residents manage their needs by been a contact to answer queries, make and manage appointments, and ensure that care homes and the residents have good quality written and verbal information Act as a point of contact for care homes, residents, families, and professionals. Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding. Provide co-ordination and navigation for people and the carers across health and care services. Helping to ensure patients receive joined-up service and the appropriate support from the right person at the right time Overall responsibility for administering the weekly Care Home MDT meetings; this will involve managing the meeting agenda, circulating information to team members in advance of the meeting, supporting the Chair, taking minutes, dealing with follow up actions and ensuring that all new referrals are identified and actioned.

Complete weekly care home rounds with allocated care homes, to identify deteriorating patients, new residents to the home, End of life residents and signpost accordingly depending on the identified need or concern raised Ensure that Personalised Care and Support Plans and EPaCCs are initiated for all patients in Care Homes; working with clinical staff to create new plans and update plans as patient needs change. Receive and collate information from transfers of care (including hospital admissions and discharges), out of hours calls etc, for Care Home patients, presenting this to the clinical staff to help identify those needing assessment. Liaise with care homes, residents, and clinicians to identify at risk residents Support the completion of new referrals by checking criteria, and where criteria have been met, referring to the MDT as required Support the Chair of the MDT by undertaking appropriate reviews or audits of Care Home Policies that support the work of the MDT., Support PCNs in developing communication channels between GPs, residents, care home staff and other agencies 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 residents circumstances Contribute to risk and impact assessments, monitoring and evaluations of the service Ensure PCSP are communicated to the GP and any other professional involved the residents care and uploaded to the relevant online care records. Review and update personalised care and support plans at regular intervals Co
- ordinate and integrate care Make and manage appointments for patients, related to primary care, secondary, community, local authority, and voluntary organisations Help care homes support a residents transition between secondary and community care services and supporting them to navigate through the wider health and care system.

Refer on to PCN clinicians or specialist services where there is an unaddressed need Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the residents care, facilitating a coordinated approach, and ensuring everyone id kept up to date so that any issues or concerns can be appropriately addressed and supported Identify when action or additional support is needed, alerting relevant clinical professionals, and highlighting any safety concerns Collaborative working relationships Collaboratively work with other Care Coordintors, managing the workload as a team and covering duties for other Care Coordinator absences. Work as a cohesive team with the other staff in the PCN, receiving referrals and identifying which PCN roles could best support the patient. Support PCN staff and patients to be more prepared to have shared decision-making conversations. Actively work toward developing and maintaining effective working relationships both within and outside the PCN, communicating effectively with service users and their families/carers, building networks with GP practices, adult social care, hospitals, community pharmacists etc.

Supporting Care Delivery Follow through actions identified by Clinical Staff or Care Home MDTs, including arranging tests, referrals, signposting etc. Follow up with service users and others involved to ensure all services and care arrangements are in place. Keep care records up to date as activities arise, uploading care plans to EMIS, identifying, and updating missing or out-of-date information about a persons circumstances etc. Supervision/professional development The post-holder will undertake regular professional development as agreed for the role, taking an active part in reviewing and developing the role and responsibilities and provide evidence of learning activity as required e.g., p

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