Care Co-ordinator

• Supporting the Duty Doctor with the coordination, follow-up and management of patients requiring additional support.
• Identifying patients who may benefit from proactive care and appropriate intervention.
• Supporting patients with long-term conditions, frailty, dementia, cancer and other complex needs.
• Coordinating care between patients, carers, GPs, community services, hospitals and other healthcare and voluntary sector organisations.
• Supporting patients and carers to navigate health and social care services and addressing barriers to accessing appropriate support.
• Maintaining accurate and up-to-date patient registers and supporting QOF targets, recalls and proactive care activity.
• Identifying patients due reviews or other aspects of care and helping to ensure these are completed.
• Undertaking appropriate patient reviews and clinical observations within your training and assessed level of competence, including dementia reviews and blood pressure checks.
• Supporting personalised care and care planning.
• Liaising with the wider multidisciplinary team to promote effective communication and coordinated care.
• Supporting carers and identifying where additional help, advice or signposting may be appropriate.
• Supporting audits, searches and other practice initiatives to improve patient care and outcomes.
• Contributing to service development and identifying opportunities to improve the way we deliver care.

• Coordinate care for patients with complex health and social care needs.
• Develop positive and supportive relationships with patients and carers.
• Help patients understand and navigate available health, social care and community services.
• Liaise with healthcare professionals and external agencies to ensure effective communication and continuity of care.
• Identify patients requiring additional support and escalate concerns appropriately.

• Undertake clinical and patient-facing activities within the individual's training, competence and agreed scope of practice.
• Undertake blood pressure checks, dementia reviews and other appropriate clinical reviews following appropriate training and assessment.
• Support clinicians with proactive patient care and recall activity.
• Recognise and escalate any concerns identified during patient contact to an appropriate clinician.

• Support the practice in achieving QOF targets and other contractual requirements.
• Maintain and update relevant patient registers.
• Identify patients who are due reviews, investigations or follow-up.
• Assist with searches, recalls and proactive care programmes.
• Support the practice to identify gaps in care and improve patient outcomes.

• Work closely with the duty doctor and wider clinical team.
• Contribute to multidisciplinary team working.
• Communicate effectively with colleagues across primary, secondary, community and social care.
• Participate in practice meetings and service improvement activity as required.

• Maintain accurate, timely and appropriate patient records.
• Ensure all activity is documented in accordance with practice policies and information governance requirements.
• Manage workload effectively and prioritise according to patient need and clinical urgency.
• Undertake administrative tasks associated with care coordination and proactive patient management.

Essential

• Experience of working with patients, carers or members of the public in a health, care, social care or similar setting.
• Experience of working as part of a team.
• Experience of managing and prioritising a varied workload.
• Experience of maintaining accurate records.

Desirable

• Previous experience within general practice, primary care, community care or another healthcare environment.
• Experience of working with patients with long-term conditions or complex needs.
• Experience of undertaking patient reviews or clinical observations.
• Experience or training in undertaking clinical observations or patient reviews.

Essential

• Minimum Grade C GCSE or equivalent in English Language and Maths or equivalent qualification
• NVQ Level 3 or equivalent

Desirable

• Care Certificate or equivalent healthcare related training

Essential

• Understanding of confidentiality and information governance.
• Understanding of the importance of person-centred care.
• Understanding of the needs of patients with complex health and social care needs.
• Understanding of the importance of accurate record keeping.
• Excellent communication and interpersonal skills.
• Compassionate and empathetic approach to patients and carers.
• Ability to work independently and use initiative.
• Ability to prioritise and manage competing demands.
• Good attention to detail.
• Good IT skills
• Ability to work effectively as part of a multidisciplinary team.
• Ability to communicate appropriately with patients who may have complex or additional needs.
• Friendly, approachable and professional.
• Reliable and organised.
• Proactive and willing to take responsibility.
• Flexible and adaptable
• Able to maintain professional boundaries and confidentiality.

Desirable

• Knowledge of QOF and primary care quality targets.
• Understanding of long-term conditions, frailty, dementia or learning disabilities.
• Knowledge of local health, social care and community services.