Care Coordinator

7 months ago

Redhill, United Kingdom The Hawthorns Surgery Full time

**Job Purpose**:
The Care Co-ordinator will have a key administrative role in working with the practice team and the wider primary/community care team to support patients with long-term medical conditions or complex health care needs. The Care Coordinator will work closely with clinicians to develop care plans and co-ordinate and monitor a range of patient services including however not limited to, frail elderly, severely mentally ill and patients with learning disabilities.

The Care Coordinator will ensure patients on their case load receive appropriate interventions to support them to live as independently as possible. This will involve working with individual patients to identify, then facilitate support they would benefit from being delivered by the voluntary sector or other health services.

The Care Coordinator will also support the practice Clinical Pharmacy team in identifying and managing a caseload of patients to ensure effective and efficient use of medicines. The role will support the team to ensure safe and effective medicines use. This will include implementing systems to monitor patients on repeat medication and supporting other processes around repeat prescribing, medicines optimisation, reducing medicines waste and maximising patient outcomes.

**Key Responsibilities**:

- Use data tools to identify those in need of proactive care. Using this information to work on a daily and weekly basis with healthcare professionals to inform their caseloads.
- Be the co-ordinator of reactive (urgent care for those in need) and proactive (planned care to support people to live independently) services for patients. Ensuring that healthcare professionals focus their limited resources on those in most need, co-ordinating the right intervention for each patient, ensuring consistent records are kept of care plans and interventions and ensuring that records are shared appropriately with all health and social care professionals involved in caring for each patient.
- Organise and facilitate multi-disciplinary meetings between members of the wider healthcare team to discuss, update and share care plans as appropriate. On occasions being ready to chair these meeting. Keep accurate records of decisions made about individual patients and follow up where necessary, ensuring health professionals act on the decisions.
- Co-ordinate collection of regular data returns to the ICB and other agencies as appropriate.
- Contact patients where appropriate to advise about health issues or provide social prescribing advice and guidance. Bring together all of a person’s identified care and support needs, and explore their options to meet these into a single personalised care and support plan.
- Co-ordinate care between GPs, other practice based clinical team members, community matrons, district nurses, palliative care nurses, community therapists, other community staff, social care, voluntary sector organisations and wider health and social care services. Work closely with the GPs and other primary care professionals to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
- Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision making conversation.
- Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
- Work with clinicians to minimise the number, and maximise the effectiveness, of appointments and home visits.
- Assist with virtual weekly ward rounds
- Pro-actively monitor the effectiveness of appointments and the reasons for non-attendance
- Send out and obtain information, especially to help empower patients to optimise self-care
- Promptly refer any patient concerns to a clinician, and act on responses
- Respond to enquiries and requests from patients, their carers and external health and social agencies
- Help to ensure patient medical conditions are being well managed, and share care plans with other clinicians or third parties where relevant
- Monitor patient information relating to (for example), A&E attendance, hospital admission and medications
- Manage and maintain registers of Long Term Condition patients and Practices clinical systems, ensuring IT security and IG compliance at all times and adding clinical codes to medical records to assist with reporting
- Undertake works in areas, such as Learning Disability, Palliative Care, Mental Health and Cervical Screening. This will include:

- Participating in local training and meetings (including taking minutes); maintaining registers; coordinating reviews; booking home visits; arranging tests; ensuring appropriate methods of communication; overseeing clinics.
- Keep up to date with Safeguard

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