Care Co-ordinator

**Purpose of the role**

Care coordinators play an important role within a PCN to proactively identify and work with people, including those with long-term conditions, Cancer, and frailty to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. Care coordinators review patients’ needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.

This role is intended to become an integral part of the PCN’s multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

Please note that the role of a care coordinator is not a clinical role.

**Key responsibilities**
- 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.
- 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.
- Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.
- 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; helping to ensure patients receive a joined-up service and the most appropriate support.
- Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
- Support the coordination and delivery of multidisciplinary teams with the PCN.
- 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.
- Explore and assist people to access a personal health budget where appropriate.
- Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies
- Identify unpaid carers and help them access services to support them
- Maintain records of referrals and interventions to enable monitoring and evaluation
- Support practices to keep care records up to date by identifying and updating missing or out-of-date information
- Contribute to risk and impact assessments, monitoring and evaluations of the service
- Work with PCN Manager, integrated locality teams and other agencies to support and further develop the role.

Key Tasks
- Take referrals for individuals or proactively identify people who could benefit from support through care coordination
- Proactively identify patients who would benefit from improved quality of care provision/ long term condition management
- Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs
- Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them
- Use tools to measure people’s levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly
- Support people to develop, implement and review personalised care and support plans, with activity recorded using the relevant SNOMED codes within patient records
- Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations
- Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system
- Refer onwards to social prescribing link workers and health and wellb