Care Coordinator

3 months ago

Oxford, United Kingdom Hedena Health Ltd Full time

Develop and implement proactive care services to help improve and maintain the health and wellbeing of our practice population.Proactively identify and work with a cohort of patients to support their personalised care requirements, using the available decision support aids. The duties and responsibilities may include any or all of the items in the following list. Duties may be varied from time to time under the direction of the Clinical Contracts Manager, dependent on current and evolving practice workload and staffing levels: To put systems in place to identify patients who are elderly, frail or who have long term health needs and support To manage a virtual ward of the highest need patients, ensuring their progress and welfare is regularly checked and update patient records with details To co-ordinate care plans, making sure actions are completed by health care professionals To utilise population health intelligence to proactively identify other cohorts of patients, working with the clinical team to plan, implement and track interventions and report on the success of these To signpost to the relevant members of the practice team and outside organisations as appropriate To contact patients following hospital discharge to offer help or support and reduce the risk of loss of independence To ensure systems are in place to monitor those at risk of increased hospital admissions and A&E attendances To follow up on communications from out of hospital and in-patient services regarding changes in condition of patients to support the practice to respond proactively to potentially unmet needs To coordinate, attend and provide administrative support for MDT meetings. To disseminate information from these meetings to other practice staff as necessary To coordinate visits or arrange appointments at the practice for patients on the caseload To manage monthly recall searches and ensure patients are attending their Long-Term condition appointments.

Following up on those not attending To maintain accurate and up to date records of patient contacts, entering notes onto EMIS Co-ordinate and liaise with patient services manager on promoting National and local Health campaigns. Use language line to communicate with patients who may otherwise not engage with our services. Completion of 2 day accredited training course as defined by Hedena.

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