Care Coordinator

7 months ago

Redruth, United Kingdom North Kerrier East PCN Full time

Work as part of the PCN health and wellbeing team, coordinating care between GPs, practice nurses, clinical pharmacists, physiotherapists, mental health practitioners, and health and well-being coaches; Record all patient contacts and work on the clinical system against the patient record; Work with individual patients, their families and carers, using a holistic approach, to identify their goals for care, and agree a personalised care and support plan for their care or support with signposting to other services; Support delivery of care plans by co-coordinating input from a range of different professionals and services, and helping patients and their carers/family to navigate across health and social care services; Help patients to manage their needs through answering queries, being a first point of contact across the PCN, and by making and managing appointments; Support patients to utilise decision aids in preparation for a shared decision-making conversation and ensure that they, and their carers/family, have access to good quality written and verbal information to help them make choices about their care; Make use of tools such as patient health questionnaires when engaging with patients; Help patients to access self-management education courses, peer support or other interventions that support them in improving their health and wellbeing. Undertake regular reviews of the personalised care and support plans developed with patients; Work in line with national best practice when developing personalised care and support plans; Work with patients over the phone, in person in the practice or for those who are housebound where necessary carry out home visits. As directed, use practice level reports to identify suitable cohorts of patients to deliver personalised care, supporting with specialist clinics; Provide accurate and timely data to support audit and monitoring of the service, and any data returns as required by the West Integrated Care Area; Keep accurate and up to date records of contacts with patients and their carers families in clinical systems and in their care plan; Follow up documentation required for care planning from other organisations, making use of Local Care Record where useful; Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations communications and patient notes and ensuring care packages are set up; Manage any necessary meetings to support care planning, identifying patients for discussion, organising the meeting and circulating required information beforehand as necessary Ensure that meeting actions are recorded, disseminated and followed up in a timely way; so relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update; Network and develop strong relationships with key organisations involved in the patients care planning; General administration duties to support the Primary Care Network Business Manager and team. Please note this is not a clinical role.

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