Care Co-ordinator

The successful applicant will support patients in preparing

for or in following-up clinical conversations they have with primary care

professionals. The applicant will work closely with the GPs and other primary care

professionals within the PCN to identify and manage a caseload of identified

patients, making sure that appropriate support is made available to them and

their carers and ensuring that their changing needs are addressed.

to support their personalised care requirements, using the available decision

support aids. For example, those

patients with a Learning Disability, Mental Health, Dementia and

vulnerable/frail patients.

and support needs and explore their options to meet these into a single

personalised care and support plan (PCSP) based on what matters to the patient,

ensuring dignity, choice, respect, independence and rights are upheld at all

times.

queries and support them to make appointments, and ensure patients have good

quality written or verbal information to help them make choices about their

care.

Identify barriers to or issues preventing greater

engagement and/or uptake by patients actively participate in developing

solutions for patients and service providers.

Support patients to take up training and

employment, and to access appropriate benefits where eligible.

Raise awareness of shared decision making and

decision support tools and assist patients to be more prepared to have a shared

decision-making conversation.

Ensure that patients have good quality information

to help them make choices about their care, e.g. Support patients to understand

their level of knowledge, skills and confidence when engaging with their health

and wellbeing.

Assist patients to access self-management education

courses, peer support or interventions that support them in their health and

wellbeing.

Act as a chaperone to provide support to patients

when appropriate or requested.

Provide co-ordination and navigation for patients

and their carers across health and care services, alongside working closely

with social prescribing link workers, health and wellbeing coaches and other

primary care professionals.

Support the co-ordination and delivery of Multi-Disciplinary

Team (MDT) meetings within practice.

Provide referral support for our clinical teams by

utilising various clinical pathways to ensure efficient and co-ordinated

patient care

Support patients with poor attendance records in vulnerable

patient groups.

Any other duties as requested by the practice

management.

Qualifications

Essential: - Demonstrable commitment to professional development

Experience

Desirable: - Experience of working in a GP surgery or in a health care environment

Personal Qualities and Attributes

Skills and Abilities