Care Coordinator

7 months ago

Salford, United Kingdom The Willows Medical CentrePCN Role Full time

SALFORD SOUTH EAST PCN

CARE COORDINATOR

**Salary**: AFC Band 4 or equivalent

Hours: 37.5

Care coordinators play an important role within the practice to proactively identify and work with certain patient cohorts to support in preparation for clinical conversations and to ensure the patients fully understand and are actively involved in managing their care.

Care coordinators will work closely with GPs and other professionals 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 fully understand the services and support available to them and to ensure their needs are met by discussing what matters to them. This is achieved by a personalised support & care plan.

Care coordinators review patient 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. The role is intended to become an integral part of the multidisciplinary team. Adopting a holistic approach and listening to the patient’s needs.

Care coordinators could potentially 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 job description will be reviewed on a monthly basis. As the role of the care coordinator is new to the practice, the requirements of this role may be developed further over time based on the needs of our patient population.

CARE COORDINATOR PERSON SPECIFICATION

Qualifications and training essential for post:

- Proficient in MS Office and web-based services
- Qualified via appropriate training (Personalised Care Institute)

KEY RESPONSIBILITIES OF THE CARE COORDINATOR
- Work with patients, their families and carers to improve their understanding of treatment plans and the healthcare services available to them within primary care.
- Support the patient to develop and review personalised care and support plans to manage patient needs and achieve better healthcare outcomes.
- Help patients to manage their needs through answering queries, making and managing appointments, and ensuring that patients have good quality written or verbal information to help them make choices about their care.
- Assist patients 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 patients 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 and local area to proactively identify and manage a specific cohort of patients, and where appropriate, refer 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 staff and patients to be more prepared to have shared decision-making conversations.
- Explore and assist patients to access a personal health budget where appropriate.
- Follow the appropriate safeguarding procedures.

Key Tasks

Enable access to personalised care & support.
- Take referrals for individuals or proactively identify people who could benefit from support through care coordination.
- Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs.
- Work towards increasing patients’ understanding of how to manage and develop health and wellbeing through offering advice and guidance.
- Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them.
- Use tools to measure people’s levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly.
- Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register.
- Support people to develop and implement personalised care and support plans.
- Review and

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