Care Coordinator inBootle inBootle PUBLISHED 27 JUN 2024

Job Overview


Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.

They can be an effective intervention in supporting people to stay well particularly those with long term conditions, multiple long-term conditions, and people living with or at risk of frailty.


Please note we are NOT able to offer Visa Sponsorship for this vacancy.



Applicants who have previously applied, within the last 6 months will not be considered



Main duties of the job


Working closely with GPs, Community Services, Care Homes and Practice Teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to patients and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.

Enhanced Health at Home.

• The Care Coordinator will work closely with GPs, practices, and other primary and community care roles and professionals within the PCN to coordinate the care of patients aged over 65 on discharge from hospital
• Help people to manage their needs through answering queries, assisting with appointments, and ensuring people understandable information to help them make independent choices about their care
• Work as part of the multidisciplinary team, building relationships with GP practices , Community services & other organisations within the PCN.
• Work with patients and families to develop personalised care plans which bring together all of a person’s identified care and support into a single plan, based on identifying what matters to the person utilising an ethos of promotion of independence, shared decision making, personalisation and partnership working
• Contribute to tackling inequalities in health and social care
• Understand, put in place, and adhere to safeguarding protocols for vulnerable individuals
  
  
  

Working for our organisation



Within South Sefton PCN Our Aims Are To

• Improve resilience in General Practice
• Build a stronger and more sustainable general practice service across the Primary Care Network footprint
• Facilitate collaborative working between all Primary Care Network practices
• Engage with local health and care providers to develop place-based care to assist in the transformation of local services to improve the health and wellbeing of the Primary Care Network population
• Work with Patient Participation Groups to improved patient access, experience and quality
• Reach out to strengthen and develop working relationships with non-NHS community groups
• Develop signposting with Primary Care Network practices to streamline the patient journey to enhance more achievable and sustainable outcomes
• Further develop digital technology as a primary resource for practices and patients
• Work in collaboration with the local GP Federation to build and strengthen relationships
  
  
  

Detailed Job Description And Main Responsibilities


As Care Coordinator your key responsibilities will include, but not be limited to:


Multidisciplinary Team (MDT) working

• Arrange the EHAH led Huddles/MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified,
  
  
  

and information circulated to team members in advance of the meeting. Record actions agreed at the meetings or take minutes and

circulate as required

• Consult with all members of the MDT to ensure its effective function.
• Work closely within the PCN roles, Community Services, Social Prescribing Link Workers, Community Matron, MDT and with GP practices within the PCN to ensure that
  
  
  

the comprehensive records of MDT case discussions are entered into clinical systems, adhering to data protection legislation and data

sharing agreements.

• Work as part of the MDT and wider PCN / Care Community to achieve its ICP (integrated care provider) directed objectives.
  
  
  

Referrals & Onward Referrals

• As part of the PCN MDT, build relationships with staff in each GP Practice within the PCN, attending practice meetings as required providing information and feedback on care coordination priorities.
• Consult directly with Community services, Voluntary Sector, Acute Trust Ward Managers, Social Care, Practice staff and other key providers to identify
  
  
  

patients for discussion at MDT, and compile and circulate relevant information to attendees.

• Refer patients to local services as required utilising providers referral processes.
  
  
  

Working with patients

• Using clinical systems and data analysis to ensure a proactive approach to identifying patients that would benefit from review.
• Alerting, referring or liaising with the relevant Service, Community Matron, professionals, family, and other services as required.
• Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision making conversation.
• Work with patients, Carers, and professionals to deliver personalised care and support planning for patients.
• Help people to manage their needs through answering queries, making, and managing appointments and ensure that patients have excellent quality information to help them make choices about their care.
• Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including
  
  
  

through use of the tools.

• Provide co-ordination and navigation for patients and their carers across health and care services, consulting with practice and PCN staff
  
  
  

including social prescribing link workers and health and wellbeing coaches.

• Seek advice and support from