Care Coordinator

6 months ago

Manchester, United Kingdom Gtd Healthcare Full time

Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, mental health workers and other primary care roles. Making and managing appointments for patients related to primary care and voluntary organisations. Help people transition seamlessly between secondary and community care services, conducting follow up appointments and supporting people to navigate through the wider health and care system. Work alongside the PCN clinicians to identify patients that require additional oneto-one support particularly with mental health issues and provide this support.

Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach, and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals and highlighting any safety concerns. Help people to manage their needs and supporting them to make appointments. Raise awareness of shared decision making, decision support tools and supporting shared decision-making conversation.

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Support the coordination and delivery of MDTs within the PCN. Collation of agendas, production of minutes / action logs for PCN / MDT meetings and ensure all actions are completed including follow up if necessary. Specific project work liaising with practice leads on implementation of shared process, and collaboration opportunities to support improved patient care.

Work collaboratively with practices targeting patients with Learning Disabilities (LD) and a Serious Mental Illness (SMI), to ensure they have annual physical health checks. Proactively identify and work with people, including the frail/elderly and those with long-term conditions. Manage a caseload of patients, working collaboratively with GPs and other primary care professionals within the PCN acting as a central point of contact to ensure appropriate support is made available to the patient. Maintain records of referrals and interventions to enable monitoring and evaluation of the service.

Have positive, empathetic and responsive conversations with the person and their family and carer(s) about their needs. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them. Support people to develop and implement personalised care and support plans (PCS). Ensure PCS plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.

Keep accurate and up to date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities and provide evidence of learning activity as required. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team.

Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning. The post-holder is required to travel independently between PCN sites, and to attend meetings etc. hosted by other agencies. Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the MDT meetings.

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