Care Co-ordinator Moorlands Rural Pcn

1 week ago

StokeonTrent, United Kingdom North Staffordshire GP Federation Full time

**Administrative Responsibilities**: 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 Raise awareness within the PCN of shared decision making and decision support tools 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 To work as a key member of the MDT to help support the development of effective MDT meetings Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers To ensure that action points identified within the MDT are recorded and followed up Under guidance from their line manager, take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team To cross reference the patients identified as high risk with the carers register within the practice to support case managers and key workers in developing holistic anticipatory care plans including prevention of carer breakdown To work with the wider MDT to identify appropriate case managers for high-risk patients to ensure that patients are reviewed, and anticipatory care plans are developed Ensure that all patients Care Plans, diagnostics results, and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available To liaise with acute hospitals, cross referencing admission data with the at risk list and coordinating the sharing of key information between the acute hospital teams and the community services Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute/community hospital setting Personal/Professional development: Participate in any training programme implemented by the PCN as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work To work in accordance with health and safety policies and procedures including reporting and recording any health and safety incident or accident Adhere to host employers adult and children safeguarding policies and procedures This job description is not exhaustive, and duties may vary with the requirements of the PCN Due to the current Coronavirus (COVID-19) the NHS has had to adjust to new ways of working which may affect initially the way you undertake the job

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