Care Co-ordinator

Surrey Downs Health & Care

A Primary Care Network team is a one team approach. To ensure our population receive the right care from the right person. We aim to do this by using our wide range of skill mix to provide high-level co-ordinated, holistic and wrap around care.

An opportunity has arisen within the Banstead PCN to join our fast-growing team of Care Co-Ordinators. If you can work autonomously with good communication skills and want to make a difference this could be the role for you.

This is an exciting and innovative role which will involve working alongside community GP’s, Paramedics, Pharmacists, District Nurses and a growing team of care coordinators to wrap care around our Banstead population as a One Team approach providing co-ordination and navigation of care and support.

Care coordinators provide extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with the Matrons and District Nurses and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, ensuring that their changing needs are addressed. They focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification.

Care Co-ordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly, those suffering with dementia, high blood pressure and those with long-term conditions, to provide co-ordination 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 Co-ordinators 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 Co-ordinators can 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.

Surrey Downs Health and Care (SDHC) deliver care closer to people’s own communities through our Primary Care Networks and our innovative partnership of local NHS organisations.

Surrey Downs Health and Care has a track record of providing person centric care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes:

- The three GP federations GP Health Partners, Dorking Health Care and Surrey Medical Network representing practices that operate in the Surrey Downs area
- CSH Surrey
- Epsom and St Helier’s University Hospitals NHS Trust
- Surrey Council County

Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us.

It’s on those grounds that the Surrey Downs Health and Care was formed - we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before.

In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.
- 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.
- Provide co-ordination 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 collaborativ