Care Coordinator

2 months ago

Bristol, United Kingdom Kingswood Health Centre Full time

Job summary

Care Coordinators provide extra time, capacity, and expertise to enable patients with enhanced needs to access the services and support they require to improve their health and wellbeing, thus helping to improve their quality of life and reducing health care inequalities.

They will ensure these patients and their carers have access to good quality information to help them make informed choices about their care and wellbeing.

They will proactively identify and liaise with an identified cohort of patients to support their personalised care requirements, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.

Care Coordinators work with groups of patients identified by local priorities, health inequalities or using population health management risk stratification. At present the current focus is on patients with Learning Disabilities (LD), adults with Severe Mental Illness (SMI) and adults looking to engage with weight loss services, but other groups will also form part of the postholders work plan.

Main duties of the job

You will proactively organise and complete health check appointments for patients where appropriate, either in their own homes or at their practice, providing them with tools to best prepare them for shared decision making conversations. This may include gathering information directly or providing information to the patient and/or carer.

You will help patients and their carers by being a point of contact/advocate. With your support, it is hoped patients will navigate or signpost effectively for their health needs and ensure they have excellent good quality written and verbal information. This may take the form of being the link between the practice, the multi-disciplinary team, or the wider healthcare community, or signposting towards services such as Social Prescribing, One You South Gloucestershire etc.

About us

4PCN's vision is to de-medicalise health problems for its patients as much as possible, and enable patients to live a healthy, happy life in the local community.

We have a fantastic team of Care Coordinators working with patients with conditions such as Learning Disabilities, Serious Mental Illness, Dementia and those who are frail and housebound.

Working across 4 practices - Hanham Health, Kingswood Health Centre, Cadbury Heath Health Centre and Close Farm Surgery our Care Coordinators visit patients in their own homes or with an appointment at their practice.

Job description

Job responsibilities

Supporting People with Learning Disabilities

You will liaise with practice teams to ensure there is a proactive call and recall system for patients 14 years of age and over with learning disabilities, booking and completing their annual health check, including taking any blood tests, blood pressure checks, height and weight measurements as required. Also providing information to help them get the most from their review. You will proactively engage with these patients, carers and the practices to ensure maximum uptake of these reviews, and follow up any patients who fail to attend their appointments You will ensure that contacts with the patient are recorded appropriately and that checks are coded and recorded accurately You will act as a link between Support Workers, the GP and any PCN, primary, community or secondary care colleagues, supporting any onward referrals, care planning or administrative planning needs as appropriate.

Serious Mental Illness Reviews

You will liaise with practice teams to ensure there is a proactive call and recall system for patients with Severe Mental Illness, booking and completing their mental health review, including taking any blood tests, blood pressure checks, height and weight measurements as required You will proactively engage with these patients, carers and the practices to ensure maximum uptake of these reviews, and follow up any patients who fail to attend their appointments You will ensure that contacts with the patient are recorded appropriately and that checks are coded and recorded accurately You will act as a link between Support Workers, the GP and any PCN, primary, community or secondary care colleagues, supporting any onward referrals, care planning or administrative planning needs as appropriate.

Administration of Weight Management Services

You will be the PCN administrative lead for these services, identifying suitable patients and making contact in the first instance You will be involved in discussions with patients to determine how motivated they are to engage with services You will book appointments and make referrals as appropriate, and may be required to gather baseline information (such as height, weight etc) as per the protocols for these services You will ensure that contacts with patient are recorded appropriately and that checks are coded and recorded accurately.

General Duties

You will ensure safeguarding issues or patient related concerns are raised appropriately to a suitable individual You will help administratively with any auditing or searching of GP clinical systems.

This job description is only a brief summary of what a Care Coordinators job will entail, and the role will expand and change over time as the needs of the PCN changes, the requirement of the Network DES expands, and the priorities of the population evolve. Any changes will be discussed with the postholder in advance and the job description will be reviewed annually during appraisal.

This list of duties is not intended to be exhaustive but indicates the main areas of work and may be subject to change to meet the changing needs of the service.

Supervision Received

The postholder will be operationally line managed by the PCN Operations Manager, with feedback and support received from the PCN Manager, Clinical Director, and other members of the PCN board.

Supervision Exercised

The postholder will not have any operational line management responsibility.

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