Care Co-ordinator

**Care Co-Ordinator**

North Cornwall Coast PCN are seeking an enthusiastic and proactive Care Co-Ordinator to join our team. We are a patient focused forward thinking PCN looking for people to work with the PCN team to deliver care to their patient populations. The Care Co-Ordinator role is an evolving role within NHS Primary Care Networks. The post holder will require a flexible approach to work, the role will consist of some focussed project work as well as general core support to the PCN. The post holders would ideally have good knowledge of community or primary care sector and good IT skills.

**JOB PURPOSE**
- The Care Co-Ordinator role is seen as a critical and evolving post to support the multi-disciplinary teams (MDTs) within the PCN to deliver effective, co-ordinated and personalised care for patients in care homes and for a cohort of elderly and frail patients.
- The post holder will work closely with teams to help and support the multi-disciplinary team (MDT) this will include the on-going patient case management. This will involve working with the GP surgeries and linking in with a range of community health and social care services, care homes and third-party services to assess the ongoing needs of patients in their own homes.
- The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. The post holder must at all times be aware of the need for confidentiality and integrity. They will also need a basic knowledge of Health and Social Care terminology and eligibility criteria and current team structures and pathways.
- To provide minor assessments of the patient and their needs to maintain safe living at home. Assessing the needs for care packages and Supporting with the referrals of equipment and technology,

**Key working relationships**
- Patients, patients families and carers
- GPs, nurses and other practice staff
- Care home managers, clinicians, carers and staff
- Case Manager and Geriatrician
- Community nurses and other allied health professionals
- Community pharmacists and support staff
- Cornwall Council Staff and equipment specialists

**Responsibilities underpinning the role**

The Care Co-Ordinator has the following key responsibilities, in delivering health services:
To assist the team to develop one single personalised care and support plan for patients to be held on the patient’s medical records and in the care homes. Holistically bring together all of a patient’s identified care and support needs, and explore options to meet these with a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.

Help patients to manage their needs by answering queries, assisting with making/ managing appointments, and ensuring that patients have good verbal or written information to help them make choices about their care.

Provide coordination and navigation for patients and their carers across health and social care services, working closely with social prescribing link workers and other primary care professionals. Explore and assist people to access personal health budgets or appropriate benefits where eligible.

Assessment of patients in their own homes who are struggling with managing their day to day living, liaising with loan stores, district nurses and Technical officers to improve safety and wellbeing.

Support patients to utilise decision aids in preparation for a shared decision making conversation.

Work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the PCN.

Raise awareness within the PCN of shared decision making and decision support tools. 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.

To act as first point of contact for professionals, GPs, care homes, community services and the third sector.

Responsible for the organisation of MDT meetings and supporting the coordination and delivery of MDTs within the PCN.

To take a lead in IT ensuring all MDT staff have access to ‘Microsoft Teams’ and have adequate equipment to participate in video meetings.

To act as a support contact for elderly and frail patients.

To follow appropriate safeguarding procedures.

**Administrative Responsibilities**

To work as a key member of the MDT to help support the development of effective MDT meetings.

To update care plan templates within EMIS ensuring accuracy with read codes used.

Lead on the IT facilitation of the MDT meetings using Microsoft teams including sending out invites to appropriate members of the MDT.

To take minutes of MDT meetings and ensure that action points identified