Community Care Coordinator

2 weeks ago

Taunton, United Kingdom Taunton Central Primary Care Network Full time

Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.

This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

Care coordinators review patients’ needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.

Care coordinators provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life.

This role is intended to become an integral part of the PCN’s multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

There may be a need to work remotely depending on the requirements of the role.

Please note that the role of a care coordinator is not a clinical role.

The job description and person specification may be reviewed on an ongoing basis in accordance with the changing needs of Taunton Central Primary Care Network and its GP member practices.

**Primary Duties and Areas of Responsibility**

**Key responsibilities**
- 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.
- Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.
- Support people to take up training and employment, and to access appropriate benefits where eligible; for example, through referral to social prescribing link workers.
- 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 within 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
- Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours
- Support PCNs 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 person’s circumstances
- Contribute to risk and impact assessments, monitoring and evaluations of the service
- Work with commissioners, integrated neighbourhood teams and other agencies to support and further develop the role.

**Key Tasks**

**Enable access to personalised care and support**
- Take referrals for individuals or proactively identify people who could benefit from support through care coordination
- Ha

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