Care Coordinator

This is an exciting opportunity for a Care Coordinator to join the Care Collaborative Primary Care Network.

This role is to support the smooth co-ordination of patient care across the Care Collaborative PCN for the benefit of our patients.

The Care Coordinator will support the Link Worker Coordinator in identifying and managing a caseload of patients, referring patients to health and social professionals as needed and providing and organising PCN Multi-Disciplinary Team Meeting on a regular basis.

The salary is £22,607.47 - 23,991.23 dependent on experience.

Alliance for Better Care CIC(ABC) is the federation of 47 East Surrey, Crawley Horsham and Mid Sussex GP practices, established in 2014, and now comprising twelve Primary Care Networks. ABC provide employment and management support to the Care Collaborative Primary Care Network comprising the following practices:

- The Wall House Surgery
- Greystone Moat House
- Moat House Surgery

**Key Responsibilities and Duties**
- To work across a Primary Care Network supporting a wide range of patients of all ages - living within Care Homes and living independently (Residential, Nursing, Learning Disability)
- To utilise soft and hard intelligence within the PCN to identify patients who will benefit from a proactive approach by the PCN, the wider community and multidisciplinary teams
- Identifying patients to discuss at PCN level MDTs where a multiple professional group attend to discuss the most complex patients, in a view to reducing unplanned admissions and exacerbation of conditions
- Coordinate weekly MDT meetings within the PCNs, alongside the Link Worker Coordinators and supporting the running of MDTs independently when the Link Workers are on leave. Ensuring that relevant professionals are in attendance, either face to face or by dial in remotely
- Uploading and maintaining patient care plans to EMIS and other relevant systems as necessary
- Maintaining action logs to audit outcomes and being able to give updates to professionals from multiple providers across the PCN, including the patients, carers and next of kin
- Ensuring all Care Homes within the PCN have a weekly check in. Phoning patients in their own homes regularly who have been identified as needing clinical and social support
- Identifying patients with and without care plans, to ensure they are up to date and shared with other agencies including the ambulance service
- Keeping up to date records in all GP clinical systems across the PCN, including data that can be reported on and shared with the PCN for outcomes, on a monthly basis
- Maintaining action logs to audit outcomes and being able to give updates to professionals from multiple providers across the PCN, including the patients, carers and next of kin
- Arranging GP ward rounds to Care Homes
- Liaising with Acute Trusts, Hospices, Community and Social Care providers as required
- Liaising with the Link Worker Social Prescriber for patients that are identified as needing well
- being support
- Ensuring Templates are completed by professionals in order to provide accurate data, by encouraging there use and auditing regularly to ensure adherence
- To support the Link Worker Co-Ordinator to Collate monthly data from each Practice within each PCN. To work with the ABC Data Analyst to compile monthly data that can be shared with the PCNs and the CCG
- Supporting the Link Worker Co-Ordinator with their daily activities

**Record Keeping and General Responsibilities**
- To keep accurate and up-to-date records of their contact with patients, carers and professionals, including the use of GP databases such as EMIS/SystmOne
- To use read codes to tag those patients identified for interventions and must be placed on the patient’s record, so that activity and metrics associated with these patients can be tracked over time by the PCN to monitor outcomes and provide data for ‘proof of concept’
- To collect data in a prescribed format as required, in order to demonstrate the impact of the service
- To actively engage with the practice teams within the PCN, ensure effective liaison with all PCN staff and contribute to the overall aims of the PCN
- To attend and contribute to relevant meetings

**Miscellaneous**
- Work as part of the team to seek feedback, continually improve the service and contribute to business planning
- Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner
- Duties may vary from time to time, without changing the general character of the post or the level of responsibility

**Person Specification**

E = Essential, D = Desirable

**Personal Qualities & Attributes**
- Ability to listen, empathise with people and provide person
- centred support in a non-judgemental way - E
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity - E
- Commitment to reducing health inequalities and p