Care Coordinator

5 months ago


St Helens, United Kingdom Hall Street Medical Centre Full time

**Care Coordinators will**: Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Be a first point of contact for those patients whose care you are supporting Be a first point of contact for patients who have been referred via the suspected cancer referral pathway from primary care into secondary care. Ensuring cancer referral safety netting. Be a point of contact for patients by letter, telephone, or face to face appointments to ensure the relevant supporting information and support is given to include the importance of their attendance at hospital appointments.

Be able to listen to a patients needs from the point of referral to newly diagnosed and beyond. To be able to manage a patient needs appropriately documenting all consultations within the patients notes. Work with patients, their families, and carers to provide support and care and manage their needs. Listen to patients needs and help to manage their needs through answering queries and sign posting to the relevant services.

Contact and organise clinical reviews for all patients with a new diagnosis with a GP where appropriate. Complete a Cancer care review with patients via telephone consultation or face to face where current COVID climate conditions permits, recording an accurate and concise consultation within the patients notes using the clinical systems. Liaise with appropriate GPs and professionals when appropriate to maximise patient needs to include identifying patients to the Gold Standard Framework (GSF) list. Build effective relationships with each practice and their staff.

Build effective relationships with local system partners such as: Cancer Alliances, Hospice Outreach team, District Nurses and Public Health. To run weekly clinical system searches for newly diagnosed cancer patients, contacting patient to arrange appointments. Contribute to increasing uptake of national screening programmes Contribute to the evaluation of the service, collate, and input timely data and suggest/implement service improvements. To produce performance and quality improvement reports as requested by PCN Leads.

Keeping up to date with National/Local Strategies. Ability to work within a team and independently. Attend and contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the service performance. Work collaboratively with the current Clinical Leads, Clinical Pharmacists, Pharmacy Technicians, Care Coordinators and Social Prescriber Link Workers, through peer support and as part of the wider Team.

Work proactively with Acute Trusts to understand the discharge process and be able to positively input into processes that optimise the patients journey. Undertake any other duties deemed appropriate by the practice or PCN Cancer Lead, practice Clinical Care Co-ordinator and practice Operational Manager. Complete annual mandatory training as required. Enrol as a member of the Personalised Care Institute to receive up to date training and opportunity to join webinars.

Participation in an annual individual performance review, including taking own responsibility for maintaining record of own personal record. Referrals Make appropriate referrals recording within the patient notes and complying with relevant data privacy and consent Seek regular feedback about the quality of service and impact of care coordination on referral agencies. Provide personalised support Work with the patient, their families and carers and consider how they can all be supported by services available to them. Bring together a persons identified care needs and explore their options to meet these within a simple coproduced personalised care and support plan, including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.

Seek advice and support from the Clinical Leads and/or identified individual(s) to discuss patient-related concerns (referring the patient back to the GP or other suitable health professional if required). Data capture Work sensitively with people, their families and carers to capture key information, enabling comprehensive and accurate records of support. Encourage people, their families and carers to provide feedback and engage fully in the care coordination process. Work closely within the MDT and with GP practices within the PCN to ensure that the comprehensive records of MDT case discussions are inputted into clinical systems, adhering to data protection legislation and data sharing agreements.

Other Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning. Contribute to the development of policies and plans relating to equ


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