Care Coordinator

**Waltham Forest Primary Care Networks Care Coordinator - Job Description**

**Job Details**

**Job title**:Care Coordinator

**Salary**:Indicative Agenda for Change Band 4

**Duration**:12 months

**Reports to (Title)**:PCN Director and Member Practices

**Department/Ward**:PCN Networks

**Location/Site**:PCN Practice Members

**Description of Role**

Waltham Forest Federated GP Network are supporting the Primary Care Networks across the borough to recruit a Care Coordinator

The Care Coordinator will work autonomously within the community, using their enhanced clinical assessment and treatment skills, to provide first point of contact for patients presenting with undifferentiated, undiagnosed problems relating to minor illness or injury, abdominal pains, chest pains and headaches. The Care Coordinator will have a key role in supporting delivery of the new Network Contract DES Service specifications.

**Job Summary**

Work within our network of GP Practices to provide a central co-ordination role for patient care planning. The role will be GP facing, with the core responsibility being excellent patient care.

Co-ordinate care packages for patients as identified by the GP across health, social care and mental health as appropriate, providing a single-point of access for staff & service users, actively managing patients’ care plan delivery

Facilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support

Identify and work with a list of named patients with the aim of encouraging independence, enabling people to remain at home, reducing unnecessary admissions to hospitals and supporting early discharge from hospital, improving the quality of care.

Work as essential team member within

Provide feedback to the practices, troubleshoot and escalate actions as necessary, providing advocacy for service users.

**Job responsibilities**
- Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames
- Explain the management of a patient’s pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms
- Work closely with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated and of the patient’s care plan, without requiring a further referral from the GP.
- Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame.
- Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations’ communications & patient notes and ensuring care packages are set up
- Collect data on patients/carers for recognised outcome measure and document for service interpretation. Ensure all patient notes are updated to reflect any changes, including details on plans
- Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and lead the meetings. Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance
- Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.
- Network and develop strong relationships with all levels of the NHS’s key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector
- Be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders

**Other duties**
- Work within the policies of scheme and Practices.
- Maintain a good working knowledge of health and safety procedures.
- Promote client involvement in the management of the service.
- Participate in regular appraisals.
- Attend training and development activities as identified and participate in meetings as required.
- Maintain administration systems and workspace used in a clean and tidy condition.
- Maintain a good working knowledge of Health and Safety procedures and fire precautions, and operate the correct procedures and participate in policy development and data collection where appr