Care Co-ordinator

1 month ago

Cambridge, United Kingdom Firs House Surgery Full time

**Main duties**:
As a Care Coordinator you will be working closely alongside your PCN (Primary Care Network) team to support people through personalised care, helping people to improve their health and wellbeing.

Care coordinators will play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

The care coordinator role will ensure patient health and care planning is timely, efficient, and patient-centred. The role will include responsibilities for the coordination of the patient’s journey through primary care and secondary care.
- To use clinical systems to identify, prioritise and contact patients requiring health checks or recalls.
- To coordinate multi-disciplinary working within the practice and to facilitate onward referrals to external services.
- Liaising with local hospitals to follow up patient referrals
- To support the practice in quality improvement programmes with a focus on improved patient care
- To contact patients with learning disability or severe mental illness prior to their annual health check and support them to attend
- To contact patients following a recent change in medical circumstances for the purposes of welfare checks and/or follow up appointments. This will include all recent hospital discharges
- To arrange regular appointments with patients who require them (e.g. INR checks)
- To facilitate shared decision making with patients, their carers and clinicians.
- To support patients with care navigation and make onward referrals as appropriate.
- To support practice staff with care navigation.
- To develop a sound understanding of the local provider landscape and disseminate relevant information to colleagues as required.
- Effectively communicate a patients’ needs within a multidisciplinary team meeting environment
- Implement and follow up key action points from the MDT meetings on to the agreed care plan which is clear and concise contemporaneous
- To provide and receive sensitive information about difficult or complex matters respecting confidentiality at all times.
- To manage and prioritise own workload without direct supervision
- To organise administrative work; maintenance of files, electronic document management systems.
- Contribute towards improved Quality Outcome Framework (QOF) outcomes for the practice
- utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care;
- 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;
- explore and assist people to access personal health budgets where appropriate;
- provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; and
- Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations;
- Identify and process any safeguarding and quality of care issues and refer onwards to ensure that clients’ welfare is protected as per agreed protocols.
- Support the coordination and delivery of MDTs within the PCN
- Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN
- Be a good communicator; have excellent written and verbal communication skills.
- Supporting in the planning and monitoring of projects.
- Planning and organising meetings when requested.
- Co-ordinating and organising project information, data and documents.
- Work autonomously on own areas of work seeking support from colleagues where expertise is required and escalating issues and concerns as necessary.
- Promote all vision and values of the PCN in all day to day activities and delivery of services.
- To undertake statutory and mandatory training and other training as and when required.
- To assist the doctors and other clinicians in the provision of a high quality service.
- Answering general enquiries, making new and follow up appointments.
- Seeking patient information and results from hospitals and other organisations.
- Liaise with hospitals for updates on patients or advise of any relevant changes in patients’ condition as directed by clinicians.
- Completing and submitting quality alerts as appropriate.
- Dealing with requests for information (e.g MASH).
- Contacting/chasing patients as requested by the Clinicians.
- Pro-actively ensuring that booked appointments are appropriate & with the correct clinician
- Overs

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