Patient Care Coordinator

We are currently seeking to recruit additional Care Co-ordinators to join our expanding care team. Working alongside our existing Care Coordinator team, Social Prescribing Link Workers and Health & Wellbeing Coaches as well as our GPs and clinical teams, you will coordinate care suited to the needs of individual patients.

If you share our values of collaboration, integrity, quality, respect and wellbeing and are looking for a new challenge, we would love to hear from you.

**Main duties of the job**

Acting as a key point of contact for patients, carers and healthcare professionals, you will ensure that an individual’s healthcare needs are addressed in a joined-up way, ensuring that they receive the right care from the right professional at the right time.

**About Us**:
Our practice has been serving the people of Fishponds and the surrounding areas for over 100 years. The surgery was founded by Dr Claude Bernard who at the time was working from a Victorian house at 564 Fishponds Road. His son Cyril then took over through the war years and the foundation of the NHS in 1948.

We are a stable practice with a fully established team. Our team consists of 5 partners and 5 salaried doctors, practice nurses and health care assistants a dietician, nurse practitioner and an advanced paramedic. Supported by a large team of care coordinators. The surgery is managed by our practice manager, deputy and management administrator.

We embrace change and technology to support process and service improvement through efficiency to help manage the workload. We hold weekly clinical meetings with the support of a friendly and approachable team. We are proud to be a training practice teaching medical students from year 1 to 5 creating a real positive vibe in the surgery. We are also part of a successful PCN enjoying the benefits of collaborative working and the exchange of ideas. We are a high QOF achiever with strong administrative process.

Deliver reception services including call handling and appropriately triage and signpost patients to the most appropriate clinician and appointment. Expanding the care navigator role to incorporate new ways of working and support patients to Holistically bring together all of a person’s identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person following the NHS Comprehensive Care Model. See also YouTube NHS Comprehensive Personalised Care Model - Explainer Animation

Contact hospitals to follow up referrals, liaise with hospitals for updates on patients or advice.

Participate in MDT meetings and patient group consultations where required.

Support patients to utilise decision aids in preparation for a shared decision-making conversation.

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, using tools to understand people’s level of knowledge, confidence in skills in managing their own health.

Support and coordinate covid, flu and immunisation clinics

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.

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.

Work with the GPs and other primary care professionals to identify and manage a caseload of patients and, where required and as appropriate, refer people back to other health professionals.

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.

Acting as a non-clinical champion coordinating referral practices safety netting, and screening activity in conjunction with the practice cancer lead.

Undertake all mandatory training and induction programmes.

Contribute to and embrace the spectrum of governance.

Take part in the ongoing development of the role through participation in training and service redesign activities.

Attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed.

Contribute to public health campaigns (e.g., COVID-19 or flu clinics) through advice or direct care.

Maintain a clean, tidy, effective working area at all times.

Support delivery of QOF and IIF, incentive schemes, QIPP and other quality or cost effectiveness initiatives.

To carry out any other reasonable duties as requested by a manager to ensure a quality and efficient service.

**Person Specificat