Care Co-ordinator for Care Homes/mdts

**Job Summary**:
The Care Co-ordinator role is a critical and evolving post to support the Multi-Disciplinary Teams (MDTs) within Seisdon Primary Care Network (PCN) to deliver effective, co-ordinated care for vulnerable and frail adults living in residential or nursing care.

The 8 GP Practices in Seisdon cover Featherstone, Bilbrook, Codsall, Perton, Wombourne and Claverley.

**Responsibilities**:
The Care Co-ordinator will work closely with the relevant teams to help and support the monthly multi-disciplinary team (MDT) meetings and ongoing patient case management. This will involve linking with the member GP surgeries, a range of Community Health Services, Social Services and Care Homes.

Also working closely with agencies involved in MDT meetings: GP Practice teams, the PCN Additional Roles workforce, Community Teams, Social Services and the Frailty service Elderly Care facilitator ensuring that there is consistent representation at meetings.

The Care Co-ordinator will demonstrate excellent organisational skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. They must at all times be aware of the need for confidentiality and integrity. They will also need a basic knowledge of Health and Social Care terminology and eligibility criteria and current team structures and pathways.

This role is a new and exciting role within Seisdon PCN network and will expand to support many other areas of care with the requirements from NHS England as part of the Long Term Plan.

The Care Co-ordinator will need to oversee the PCN employed additional roles and co-ordinate training, leave and absences while working closely with the PCN Clinical Director and Manager.

**Scope and Purpose of the role**

The Care Co-ordinator will be a pivotal part of the MDT team, by:

- Planning and co-ordinating the MDT meetings, clinical and social care as agreed with the supervising practitioner in line with clinical governance and within agreed professional standards and guidelines.
- Working pro-actively as a member of the multi-disciplinary team in support of the member practice teams.

The Care Co-ordinator will provide support to the Clinical Director and PCN Manager in overseeing the PCN employed staff.

**Clinical Liaison Responsibilities**
- Working closely with the member GP practices within Seisdon PCN to help ensure wrap around support for patients in residential or nursing care or the frail elderly in the Community.
- Deliver and effectively communicate integrated patient centred-care through appropriate working with the wider primary care multi-disciplinary team and social care networks.
- To act as the first point of contact for professionals making enquiries to the MDT.
- To provide co-ordination of pro-active MDT care for care homes and identified frail patients.
- Supporting the PCN Care Home DES for patients in nursing or care homes and assisting member practices in the deliver key annual reviews and immunisations. This may require co-ordinating practice, PCN Additional Roles and Community teams.
- To work with the wider MDT to identify appropriate high risk patients to ensure that patients are reviewed and anticipatory care plans are developed in an agreed timeframe.
- To obtain consent from patients identified by the Frailty pathway to be discussed at the MDT and for onward referral into the Staying Well Service.
- Where appropriate to be a point of contact for patient, carers and family members ensuring good communication between GP services and patients, relatives or carers.
- To be a point of contact for care homes staff and proactively developing strong communication links with assigned care homes.
- To provide co-ordination for new objectives and projects as defined by NHS England as required

**Administrative Responsibilities**
- To work as a key member of the MDT to help support the development of effective MDT meetings, preparing agenda’s, minutes and communicating attendee information.
- To ensure that action points identified within the MDT are recorded and followed up
- Under guidance from the practice managers, take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team.
- To cross reference the patients identified by the MDT team, supporting the development of personalised care and support plans, as well as ensuring reviews are carried out within agreed timeframes.
- Ensure that patients’ Anticipatory Care Plans, relevant results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available.
- Inputting into the patient electronic records in line with professional and organisational requirements where necessary.
- To be a point of contact for the ARRS workforce updating training, leave and absences while working closely with the PCN Clinical Director and Manager