Primary Care

Title**:Job Description - Care Coordinator**
Reference: BRHC/JD/CC/01

Date**:19 July 2023**

**Job Description - Care-Coordinator**

**Salary**:Dependant on experience [TBC]

**Reports to**:Lead Nurse/Practice Director **Accountable to**:BRHC Partnership

**Hours of Work**:Part Time [22.5 hours/week] **Contract Type**: Permanent

**Job Summary**:
Bodmin Road Health Centre [BRHC] is a Primary Care provider based in Sale, Manchester and is part of the Sale Central Primary Care Network. Our services are diverse, and forward-thinking enabling us to deliver patient centred care to meet local priorities in relation to chronic disease, improved ac
- cess and general care management.

We provide high quality general medical care to a registered list of over 9,000 patients, through our dedicated team of clinical, administrative and management professionals.

The Care Co-ordinator will be expected to assist clinical personnel in the care of practice patients to include enhanced access, preventative care, screening, and patient education. The post will also in
- clude some administrative duties. The Care Co-ordinator will act as a focal point of communication between patients and the health centre enabling effective and safe navigation of patient needs both internally and externally of the health centre.

Working innovatively and closely with GPs and practice teams to support carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed

**Key Responsibilities**:
The post holder will undertake work in line with BRHC directed priorities.

Proactively identifying and working with a cohort of people to support their personalised care requirements. This could include:

- the development of digital solutions across the health centre supporting access needs of patients;
- care navigation of patients contacting the practice to better meet their access needs;
- supporting the co-ordination of personalised annual recall invites for patients with long term conditions;
- Engaging with and developing processes in support of localised, agreed, access processes.
- Facilitating enhanced processes to support the care coordination of patients with complex need.
- Facilitating patient group consultations supporting effective and efficient care delivered by clinical team members

Proactively supporting and assisting with the development of patient access activity coordinating patient access into and external of the health centre in a timely and safe manner.

Resolving any queries in relation to these workstreams and ensuring all parties are kept informed of pro
- gress towards resolution.

Supporting Quality and Outcome Frameworks and other DES specifications.

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

Facilitating and supporting the development of localised clinical group consultations.

Bringing together patients identified care and support needs and exploring their options to meet these into a single personalised care and support plan (PCSP), in line with PCSP best practice.

Assisting people to access self-management education courses, peer support or interventions that sup
- port them in their health and wellbeing.

Providing coordination and navigation for patients/carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles.

Supporting residents in care homes/LD homes ensuring personalised care is delivered through collabo
- rative working between health, social care, voluntary, community and social enterprise sector and care home partners.

At times you will be required to support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them, and educating them to promote and support their independence.

Be proactive in developing strong link with local agencies, and in encouraging equality and inclusions

**Partnership working and communication**

→ Develop strong working relationships with GPs, practice teams and other health care col
- leagues to optimise the timely and good quality delivery of services to patients and to support the working lives of colleagues.

→ Work collaboratively with neighbourhood colleagues to share best practises.

→ Ensure that all relevant professionals are kept up-to-date so that any issues or concerns can be appropriately addressed and supported.

→ Keep accurate, up-to-date, contemporaneous and appropriately Snomed coded consulta
- tion records of patient contacts, appropriately using EMIS software and other record, re
- ferral and messaging systems relevant to the role, adhering to information governance and data protection legislation.

→ Maintain records of interventions to enable monitoring and evaluation of the service.

→ Provide