Care Coordinator

2 months ago

Wellington, United Kingdom Wellington Medical Centre Full time

Key Responsibilities Ensure that all patients are contacted on discharge from hospital, their current needs are reviewed, and further support and signposting offered. To bring those patients relevant to the MDTs for further discussion and support. Be responsible for contacting patients who may have attended A+E inappropriately as a way of managing their long-term condition and review their needs and support them to engage with the GP practice. Direct patient facing work Manage a caseload of patients identified via the three practices Support patients to manage their medications and social needs on discharge.

Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. 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 take up training and employment, and to access appropriate benefits where eligible. 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.

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. Explore and assist people to access personal health budgets where appropriate. Communication and collaborative working relationships Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs. Liaise with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, Pharmacists other practice staff and other healthcare professionals including Care Coordinators.

Develop excellent working relationships with the all partners, wider service networks including the voluntary sector, GP practices, Regional Screening Team, Cancer Alliances, Macmillan Cancer Support, Adult Social Care, Hospitals, Community Pharmacists and other members of the MDT. Meet regularly with the Clinical Lead and review caseload and MDT function. Keep the PCN aware of good news stories. Provide background information about individuals for the regular MDT meetings.

Communicate effectively with service users and their families/carers, and provide coordination across health and care services working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Manage and prioritise workload on a daily basis. Other responsibilities To act at all times in an anti-discriminatory manner. To be able to plan and respond to workload according to operational priorities.

To support the delivery of these functions across wider locality areas where necessary. To undertake any training required in order to maintain competency including mandatory training. To contribute to, and work within a safe working environment. To carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures.

To take responsibility for self-development on a continuous basis, undertaking on the-job training as required. To be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment. Patient Care Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding. Effectively use all methods of communication, be aware of, and manage barriers to communication.

Effectively recognise and manage challenging behaviours, carers and or relatives. Provide information to patients, their carers and/or relatives on behalf of the team. The PCN will ensure the PCNs Care Coordinator can discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with a relevant GP.

Supporting Care Delivery Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated. Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc. Follow through with service users and others involved ensuring all services and care arrangements are in place. Autonomy/Scope within Role The post holder will be required to work within clearly defined organisational protocols, policies and procedures.

**Key Relationships Key Working Relationships Internal**: Clinical Lead for the central PCN team GPs and General practice teams within the PCN PCN Clinical Direc

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