Long Term Conditions Care Co-ordinator

This list of duties and responsibilities, which follows, represents the broad range of tasks which may be required to be undertaken either routinely or periodically. This list is not exhaustive, and the role may include additional duties which are not listed here. 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 Work collaboratively with the practice team to proactively identify patients with long-term conditions to add to their caseload To refer back to, or liaise with, health and care staff as appropriate to help meet the needs of the patient. Support practices in developing communication channels between GPs, people and their families Work with people and their families and carers and healthcare team members to encourage effective help-seeking behaviours Maintain records of referrals and interventions to enable monitoring and evaluation of the service Key tasks Enable access to personalised care and support Take referrals for individuals or proactively identify people who could benefit from support through care co-ordination Have a positive, empathetic and responsive conversation with the person and their family and carers about their needs Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance Pro-actively develop an in-depth knowledge of, and links with, 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 Write care and support plans which are simple, co-produced and personalised Ensure patients are clear what to expect from the groups, activities and services they are supported to connect with Be supportive but promote what the person can do for themselves to improve their health and wellbeing Review and update personalised care and support plans at regular intervals Ensure plans are clearly recorded in the patients electronic record to communicate with the practice team and other professionals involved in the patients care.

To be involved in multidisciplinary clinical meetings within the practice, the ICC and across the PCN where appropriate Co-ordinate and integrate care Make, manage and support attendance at appointments/activities for patients in health and statutory services and in the community. Refer onwards to health and council social prescribing link workers and health and wellbeing coaches where required Actively participate in multi-disciplinary meetings about the patient to keep everyone informed Identify when action or additional support is needed, alerting a named clinical contact in addition to other relevant care professionals, and highlighting any safety concerns Assist people to access self-management education courses, peer support or interventions and activities that support them in their health and wellbeing and increase their activation level Record what interventions are used to support people and how people are developing on their health and care journey Keep accurate and up-to-date records of contacts using appropriate clinical templates and coding within EMIS, adhering to information governance and data protection legislation. Support the achievement of practice local and national quality standards, e.g. QOF, IIF and GPQC Support early diagnosis and prevention of cancer, encouraging take-up of screening and understanding of symptoms Encourage people, their families and carers to provide feedback and to share their stories about the impact of care co-ordination on their lives Record and collate information according to agreed protocols and contribute to evaluation reports require for the monitoring and evaluation of the service.

To undertake a proactive role in audit and quality improvement implementing recommendations where appropriate Work with practice to ensure full compliance with Care Quality Commission standards for safe and effective care. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonable required from time-to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner. Professional Development Work with a named clinical contact for advice and support 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.