Health Care Coordinator inEden inEden PUBLISHED 19 DEC 2023

Main duties/Key tasks:

• Undertake comprehensive geriatric assessment and/or annual review on all patients scoring moderate to severe on the practice frailty register
• Keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances;
• Highlight any safety concerns.
• Maintain records of referrals and interventions to enable monitoring and evaluation of the service;
• To provide patients with high quality, easy to understand information to assist them in making choices about their care.
• To take a holistic approach, based on the persons priorities, and the wider determinants of health.
• To assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools
• Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
• Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
• Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
• Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN.
• Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes;
• Take referrals for individuals or proactively identify people who could benefit from support through care coordination;
• Explore and assist people to access a personal health budget where appropriate.
• Identify unpaid carers and help them access services to support them;
• Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;
• Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality diversity and inclusion training and health and safety
• Work with Team leader for advice and support.
• Act as a champion for personalised care and shared decision making within the PCN

Key Result Areas

• Actively collect and maintain data that will demonstrate patient improvement in key areas.
• Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve Primary Care Network and local population objectives.
• To take an active role in risk assessment, supporting implementation of strategies to minimise risk. Ensuring incidents and near misses are reported, through promoting a no blame culture.
• Act in accordance with GP Practice and Statutory Guidelines and Policies, including Health and Safety initiatives.
• Will work in accordance with Network priorities and objectives.
• Effectively manages own time, workload, and resources.

Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.

This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

Care coordinators review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.

Their aim is to help people improve their quality of life.

The successful candidate will be caring, dedicated, reliable and person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.