Care Co-ordinator

7 months ago


Wolverhampton, United Kingdom GP First Ltd Full time

Scope and Purpose of the role The Care Co-ordinator will be a pivotal part of the MDT team, by: Planning and co-ordinating the MDT meetings, clinical and social care as agreed with the supervising practitioner in line with clinical governance and within agreed professional standards and guidelines. Working pro-actively as a member of the multi-disciplinary team in support of the member practice teams. The Care Co-ordinator will provide support to the Clinical Director and PCN Manager in overseeing the PCN employed staff. Clinical Liaison Responsibilities Working closely with the member GP practices within Seisdon PCN to help ensure wrap around support for patients in residential or nursing care or the frail elderly in the Community.

Deliver and effectively communicate integrated patient centred-care through appropriate working with the wider primary care multi-disciplinary team and social care networks. To act as the first point of contact for professionals making enquiries to the MDT. To provide co-ordination of pro-active MDT care for care homes and identified frail patients. Supporting the PCN Care Home DES for patients in nursing or care homes and assisting member practices in the deliver key annual reviews and immunisations.

This may require co-ordinating practice, PCN Additional Roles and Community teams. To work with the wider MDT to identify appropriate high risk patients to ensure that patients are reviewed and anticipatory care plans are developed in an agreed timeframe. To obtain consent from patients identified by the Frailty pathway to be discussed at the MDT and for onward referral into the Staying Well Service. Where appropriate to be a point of contact for patient, carers and family members ensuring good communication between GP services and patients, relatives or carers.

To be a point of contact for care homes staff and proactively developing strong communication links with assigned care homes. To provide co-ordination for new objectives and projects as defined by NHS England as required Administrative Responsibilities To work as a key member of the MDT to help support the development of effective MDT meetings, preparing agendas, minutes and communicating attendee information. To ensure that action points identified within the MDT are recorded and followed up Under guidance from the practice managers, take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team. To cross reference the patients identified by the MDT team, supporting the development of personalised care and support plans, as well as ensuring reviews are carried out within agreed timeframes.

Ensure that patients Anticipatory Care Plans, relevant results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available. Inputting into the patient electronic records in line with professional and organisational requirements where necessary. To be a point of contact for the ARRS workforce updating training, leave and absences while working closely with the PCN Clinical Director and Manager. Expectation to undertake and participate in training as required.

Health and Safety and Risk Management To comply with the Health and Safety at Work Act 1974 and PCN Health and Safety policies in particular following agreed safe working procedures. To comply with the Data Protection Act (2018) and the Access to Health Records Act (1990) and data sharing agreements. Equality and Diversity To carry out responsibilities in line with Equal Opportunities policies and procedures. Confidentiality To maintain confidentiality of information relating to patients, staff and other users of the service in accordance with the Data Protection Act and Caldicott Guardian guidance.

Communication and Working Arrangements The post-holder will establish and maintain effective communication pathways with the following: Clinicians and managers in the PCN practices Nurses and managers in the aligned care homes Relatives of patients where applicable Clinicians and administrators in the Community Teams The PCN Additional Roles team. Special Working Conditions To undertake duties at the PCN member practices as required. Undertake tasks consistent with the level and scope of the post and ensuring work is delivered in a timely and effective manner. Indirect exposure to emotional circumstances (details at MDT meetings and processing details of terminally ill patients) During the Covid pandemic MDT meetings have been conducted virtually.

Some meetings may revert back to meeting at practices sites in the future. Rehabilitation of Offenders Act 1994 Because of the nature of the work, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1994 (Exceptions) Order 1995. Applicants for posts are not entitled to withhold information about convictions which for other purposes



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