Care Coordinator

This role will be hosted by South East Leeds GP Group, and will be based in Cross Gates Primary Care Network (PCN).

Cross Gates PCN has a patient population of circa 30,000 across 4 practices:

- Ashfield Medical Centre
- Colton Mill Medical Centre
- Family Doctors
- Manston Surgery

We are a dynamic, forward thinking team, which is passionate about developing and delivering excellent quality local services to meet the needs of our patients.

We are very excited to be recruiting a Care Coordinator to join our PCN team, which currently includes pharmacists, pharmacy technician, mental health practitioners, advanced clinical practitioner, paramedics and care coordinators. In addition, we have plans in place to recruit to other roles including nurse associates and occupational therapists.

**Job summary**

Our Care Coordinators will play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They will be working closely with practice and PCN staff to identify, engage with and proactively coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, people living with severe mental illness or learning disabilities, and those with long-term health conditions.

As well as being linked with individual practices they will work together as a team. This will include sharing learning and best practice both within the team and across the PCN.

Our Care Coordinators will support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings including weekly Care homes meetings.

To run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, and other services including self-management services. Support with patient engagement, which will include ensuring that information is accessible for all, and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.

To support people in preparing for or following-up clinical conversations they have with primary care professionals (including health checks) to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.

Act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. 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.

**Key responsibilities**
- Coordinate multidisciplinary meetings across local care organisations including identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.
- Provide admin support to multidisciplinary meetings including taking minutes.
- Utilise GP Practice clinical systems (SystmOne) and population health data to proactively identify relevant cohorts of patients to deliver personalised care
- Support patients within these cohorts to access health checks and other health services
- Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system
- Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations
- Assist patients and carers in managing their own needs, answering their queries and supporting them to address their needs
- Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding
- Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care
- Raise awareness of shared decision making and decision support tools, and assist patients to be more prepared for shared decision making conversations
- To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN
- Work in partnership with key providers in the local community to enable improved access to services for patients
- Actively engage with, assist and provide advice to carers, to enable them to sustain their caring role escalating