Care Coordinator

**Hedena Health Ltd**

**Care Coordinator (Administrator)**

**Are you looking to join a progressive, thriving organisation at the forefront of providing high quality patient-centric care in Oxford?**

With 28,000 patients, Hedena Health is one of Oxford's largest providers of Primary Healthcare services. From 3 sites in the Headington area, the group runs team-based care, to ensure the best for our patients.

We are seeking an enthusiastic and motivated Care Coordinator to join our Clinical Contracts Team.

**Job Summary**

We are looking to recruit a Care Coordinator to provide clinical admin support to our Multi-disciplinary team (MDT). The role will be varied and include coordination of clinics, imputing of clinical data and direct patient contact to encourage uptake of services. You would play an important role to proactively identify and work with people, including the frail/elderly and those with long term conditions, as well as outreach work of patients who may not be engaging with our services.

You would work closely and in partnership with the practice clinical teams, including Social Prescribers, Clinical Pharmacists and other members of the PCN multi-disciplinary teams providing coordination and navigation for patients and their carers across health and care services.

To be successful in this role you will ideally have experience of working in the NHS with knowledge and understanding of the roles of the NHS organisation and of the primary care sector. Benefits include 5 weeks annual leave and NHS Pension Scheme.
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**Job Description and Person Specification**

**Job Title**: Care Coordinator

**Responsible to**: Clinical Contracts Manager

**Responsible for**: Working with our contracts team to develop and implement proactive care services to help improve and maintain the health and wellbeing of our practice population.

**Hours of work**:Part - Full time (over at least 4 days)

**Job Summary**:
We are looking to recruit a Care Coordinator to provide clinical admin support to our Multi-Disciplinary Team (MDT). The role will be varied and include coordination of clinics, imputing of clinical data and direct patient contact to encourage uptake of services. You would play an important role to proactively identify and work with people, including the frail/elderly and those with long term conditions, as well as outreach work of patients who may not be engaging with our services.

You would work closely and in partnership with the practice clinical teams, Social Prescribers, Clinical Pharmacists, and other members of the PCN multi-disciplinary teams providing coordination and navigation for patients and their carers across health and care services.

**Key Duties & Responsibilities**:
Develop and implement proactive care services to help improve and maintain the health and wellbeing of our practice population. Proactively identify and work with a cohort of patients to support their personalised care requirements, using the available decision support aids.

The duties and responsibilities may include any or all of the items in the following list. Duties may be varied from time to time under the direction of the Clinical Contracts Manager, dependent on current and evolving practice workload and staffing levels:

- To put systems in place to identify patients who are elderly, frail or who have long term health needs and support
- To manage a virtual ward of the highest need patients, ensuring their progress and welfare is regularly checked and update patient records with details
- To co-ordinate care plans, making sure actions are completed by health care professionals
- To utilise population health intelligence to proactively identify other cohorts of patients, working with the clinical team to plan, implement and track interventions and report on the success of these
- To signpost to the relevant members of the practice team and outside organisations as appropriate
- To contact patients following hospital discharge to offer help or support and reduce the risk of loss of independence
- To ensure systems are in place to monitor those at risk of increased hospital admissions and A&E attendances
- To follow up on communications from out of hospital and in-patient services regarding changes in condition of patients to support the practice to respond proactively to potentially unmet needs
- To coordinate, attend and provide administrative support for MDT meetings. To disseminate information from these meetings to other practice staff as necessary
- To coordinate visits or arrange appointments at the practice for patients on the caseload
- To manage monthly recall searches and ensure patients are attending their Long-Term condition appointments. Following up on those not attending
- To maintain accurate and up to date records of patient contacts, entering notes onto EMIS
- Co-ordinate and liaise with patient services manager on promoting National and local Hea