Care Coordinator with a Focus On Cvd

4 months ago

Brigg, United Kingdom The Central Surgery Full time

As a Care Coordinator you will play an important role within NCN to proactively identify and manage people identified as living with, or at risk of developing diseases. There will be a particular focus during the first year of employment on cardiovascular conditions such as high blood pressure, high cholesterol, diabetes, coronary heart disease and strokes. A key part of the role includes undertaking health assessments and identifying and coordinating appropriate referral routes to improve patient outcomes through coordinated access to support and advice across health, care and local voluntary and community services. You will work closely with practice teams to support patients and carers to understand and manage their conditions and ensuring their changing needs are addressed in a holistic manner.

As well as providing care coordination the role will involve hands on patient care such as blood pressure checking, phlebotomy, ECG taking and INR measurement. Key responsibilities Undertake NHS health checks and record findings in clinical systems, working to necessary protocols and policies, assessment of risk, communication of results and onward referral. Deliver drop-in sessions for patients to have height and weight checks along with support and signposting to allied 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. Coordination of ambulatory and home BP monitoring services.

This will include identifying patients, loaning of the equipment with delivery of appropriate patient training, adding results to patient records, organising follow up onward referrals as appropriate according to protocols. 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.

Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, 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 to other health professionals 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. Work with people, their families, carers, and healthcare team members to encourage effective self-management of health conditions (when appropriate) 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 persons circumstances 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 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.

Professional development Work with a named clinical point of contact for advice and support. Undertake continual personal and professional development Adhere to organizational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers

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